To report on the review of the English language controls

Report on the review of the English language controls Item 12 Council 22 June 2017 Purpose of paper Action Corporate Strategy 2016-19 Business Plan 2017 To report on the review of the English language controls following implementation in 1 April 2016. For approval. Professionals Objective 4: To guide dental professionals in meeting the standards we set for them, taking into account patients current needs. Priority three: Drive improvement in dental regulation Decision Trail 3 March 2016 Council approved the statutory guidance relating to the English language requirements for registration and approved an increase in the International English Language Testing System (IELTS) level required for dental nurses and dental technicians from 6.5 to 7.0 from 1 April 2016. 27 January 2016 Council considered the consultation report on the guidance and requested further information on the IELTS levels. 2 October 2015- Council approved the draft Guidance for consultation. 17 June 2015 - Council agreed the draft guidance and the policy approach subject to further work on the proposed IELTS test levels Recommendations The EMT Board is asked to consider and recommend the updated guidance to the Council. Authorship of paper and further information Nyree Connell, Corporate Policy Manager nconnell@gdc-uk.org Patrick Kavanagh, Policy Manager pkavanagh@gdc-uk.org Matthew Hill, Executive Director - Strategy mhill@gdc-uk.org Appendices Statutory guidance for applicants on evidence of English language competence. Page 1

Structured reference to demonstrate language competency 1. Executive summary 1.1. In 2016, following a change to the Dentists Act 1984, the GDC was granted new powers to assess the language competence of dental professionals from the EEA prior to registration, in line with the language competence requirements already in place for applicants from outside the EEA. The evidence requirements in place for non-eea applicants set an acceptable pass score for the International English Language Testing System (IELTS). Under this arrangement the score requirements were not the same for all dental professionals, with dental nurses and dental technicians having a lower score requirement than other dental professionals. 1.2. In anticipation of the new powers coming into force in April 2016, the GDC developed guidance setting out the evidence requirements in respect of an applicant s English language competence, referring to a range of differing types of evidence, including a recent IELTS pass score or a recent dental qualification that had been taught and examined in English. At the same time, the acceptable IELTS pass scores for dental nurses and dental technicians were, by agreement of Council, and were set out in the published guidance. The score levels for all dental professionals are therefore now the same. It was agreed by Council that a review of the impact of the new powers and the changes to the IELTS scores for dental nurses and dental technicians would take place 12 months after implementation. 1.3. The aim of the review was to establish the impact of language controls on patient safety, numbers of applicants to the register and to consider any evidence for making changes to the current requirements in relation to IELTS scores. 1.4. An evidence review has been undertaken. It showed that the introduction of language controls had a limited impact, with no change in the numbers of applications from dental nurses and dental technicians from within the EEA and with the numbers of fitness to practise concerns regarding fluency in English remaining very small. 1.5. Therefore, no evidence exists to suggest that the IELTS score levels should be changed. about it should also be noted that an increase in IELTS levels would constitute an increase in barriers to the movement of professionals. We note from the experience of other regulators that the introduction of language controls has led to a decline in applicants which could be attributed to IELTs score levels. As highlighted above, the current levels set for dental professionals appear adequate in terms of patient safety and public protection. However, we will continue to keep the IELTS score levels we set under review. 1.6. Some minor amendments have been made to the guidance, including the introduction of a structured reference, which is a tool used by other regulators. 1.7. Council is asked to note the conclusions in this paper, and approve the revised guidance. 2. Introduction and background 2.1. The GDC, along with other healthcare professional regulators, worked with the Department of Health to introduce new powers to assess English language proficiency for applicants from the EEA. These new powers, which came into force on 1 April 2016, enabled the GDC to assess the English language proficiency of all dental professionals prior to registration. 2.2. Previously, European law had prevented us from seeking evidence about English language skills from European Economic Area (EEA) qualified dental professionals. However, the EU Page 2

Directive 2005/36/EC on the recognition of professional qualifications ( the Directive ) was amended and enabled us to carry out language controls. The changes applied to: - EEA applicants for registration - Non - EEA applicants for registration - EEA applicants seeking restoration to the register - Non - EEA applicants seeking restoration to the register 2.3. The changes to the Act brought about by the Order required us to publish guidance setting out the criteria which the GDC would apply when determining whether an individual satisfied our requirement that they had the necessary knowledge of English. 2.4. The necessary knowledge of English was defined in the revised Dentists Act 1984 as a knowledge of English which, in the interests of the person and the person s patients, is necessary for the practice of dentistry in the UK. We elaborated on this general definition in accordance with our Standards for the dental team, which state: You must be sufficiently fluent in written and spoken English to communicate effectively with patients, their relatives, the dental team and other healthcare professionals in the United Kingdom 1. 2.5. In addition, because the GDC could be challenged for infringing EU law if it put in place evidence requirements and criteria which unnecessarily restricted the free movement of EEA professionals, we took steps to ensure that the guidance and the evidential criteria set were compliant and applied in a non-discriminatory manner. 2.6. We modelled our guidance on the GMC s guidance (in force since 2014), which had been subject to external expert legal scrutiny and had also satisfied the European Commission that it was compatible with EU law. 2.7. In accordance with the legislation, we consulted on the statutory guidance (October 2015 January 2016), which set out the approach that would be taken to the assessment of attainment levels in English and the type of information that would be accepted from applicants to demonstrate that they had the necessary knowledge of English. The types of acceptable evidence included, among other things, a recent IELTS test with an adequate score, a recent primary dental qualification that had been taught in English and recent experience of practising in a country where the first language is English. The consultation also invited responses on the use of the IELTS and on the pass scores required. These were proposed as being 6.5 for dental nurses and dental technicians and 7 for dentists and all other DCPs. These were the scores that were at that time required for dental professionals who had qualified from outside the EEA. 2.8. The consultation exercise highlighted that there was strong support for the types of evidence set out in the statutory guidance. However, concerns were expressed by respondents about the adequacy of the IELTS test for clinical settings. 2.9. The Council decided, based on the responses to the consultation exercise, to approve an increase in the IELTS level required for dental nurses and dental technicians from 6.5 to 7.0 which meant that all dental professionals were required to attain the same level of English language proficiency. The requirement for the IELTS score for dental professionals is an overall average of 7, with a minimum score of 6.5 in each of the component parts of the test. 1 Standards for the Dental Team - Standard 2.1.2 Page 3

3. Scope of the review of English language controls 3.1. We committed to reviewing the impact of language controls one year after implementation and to considering any evidence for changing the current requirements in relation the IELTS scores. The review covered the 12-month period from implementation on 1 April 2016 3.2. The review evaluated any issues arising from the current guidance for registrants and assessed any evidence that the current pass levels set for IELTS should be maintained or changed. 3.2. Separate research has recently been carried out into the Overseas Registration Examination (ORE) which highlighted some concerns about the communication skills of international applicants. This finding does not conflict with the review of the implementation of language controls as the scope of the review was different from the ORE research and focused specifically on the impact on numbers of applicants since the controls were implemented, the IELTS scores set as well as patient safety issues as outlined below (3.3). 3.3. The review considered the impact of the controls on the following areas: Numbers of dentist and dental care professional applicants (by route of registration) applying to the registers Impact of the changes to the IELTs levels on numbers of DCPs applying for registration A breakdown of evidence presented across application types (including o o restoration and renewals to the register applicants who did not meet requirements set out in the guidance plus numbers directed to take the IELTS Impact on patient safety We also met with and considered the experiences of other health and non-health regulators in terms of setting the IELTS score levels. 4. The outcome of the review 4.1. The data: EEA applicants to the registers 4.1.1. For many years, EEA-qualified individuals made up 16-17% of the dentists register and around 1% of the dental care professional register. The majority of EEA dentists are able to apply for GDC registration under the automatic recognition regime of the Professional Qualifications Directive whilst a minority of EEA dentists and all dental care professionals are assessed under the general systems regime. 4.1.2. The introduction of language controls from April 2016 was entirely new for these groups and might have been anticipated to be particularly significant for the automatic recognition route. Other health profession regulators have reported upon a sizeable spike in such applications in the months leading up to the introduction of language controls followed by considerably less applications following the introduction. 4.1.3. Our experience with dentists and dental care professionals across the relevant period has been comparatively stable (see table 1): Page 4

Table 1 registration data April 15- March 2017 160 140 120 100 80 60 40 20 0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 EEA Dentist Applications Received EEA DCP Applications Received EEA Dentist Applications Registered EEA DCP Applications Registered Graph depicting registration data in Table 1 4.1.4. No significant spike in applications was received pre-april 2016. 4.1.5. Both applications and registrations for dentists in the year following the introduction of language controls are running at the level of 70% of the preceding year. Whilst there has been a continuing trend in lessening numbers of EEA-qualified applicants being registered in recent calendar years, this drop is potentially significant, although it is not possible, given other factors, to attribute this to the introduction of language controls. Page 5

Table 2 EEA dentist applications 4.1.6. While there was a reduction in the number of dental care professional applications in the year following the introduction of controls, the numbers registered in that year remained the same. We continue to see a gradual increase in the number of EEAqualified dental care professionals being registered (2014 = 316; 2015 = 377; 2016 = 438) and language controls do not thus far appear to be impacting upon this trend. 4.1.7. We will continue to monitor and report upon these trends in future years. 4.2. The data: non-eea applicants to the registers 4.2.1. Language controls existed before April 2016 for Non-EEA qualified applicants to our registers but the guidance introduced at that time meant we applied the same proportionate approach to the supply of evidence as we introduced for EEA-qualified applicants and, for dental nurses and technicians, the IELTS levels required, when necessary, increased to the same level as for dentists. 4.2.2. The number of applications and successful applicants to join the ORE waiting list has increased in the year following the introduction of language controls. It is likely the major factor influencing this is more likely to be examination availability than any perceived relaxation of controls. 4.2.3. The numbers of non - EEA qualified dental nurses and dental technicians continued to increase before and after the change to relevant IETS requirements the numbers are small and do not provide a robust basis at this time for analysis: 4.3. Evidence presented by applicants Table 3 non-eea qualified 4.3.1. The following table shows a breakdown of the type of evidence presented by applicants in respect of their English language competence. It should be noted that these figures are based on the range of successful and unsuccessful applications (and not registrations) across the route to registration so that the same application may appear more than once. Page 6

Table 4 English language evidence Evidence type 1: An International English Language Testing System (IELTS) certificate at the appropriate level Evidence type 2: A recent primary dental qualification that has been taught and examined in English Evidence type 3: A recent pass in a language test for registration with a regulatory authority in a country where the first and native language is English Evidence type 4: Recent experience of practising in a country where the first and native language is English 4.3.2. As of the end of April 2017, 27 applicants out of 1107 have been required to take the IELTS examination, because the evidence they originally provided was not deemed satisfactory. 4.4. Impact on public safety 4.4.1. There have been no related/relevant suspensions or erasures since the language controls came into force in April 2016. Prior to the implementation of the controls, one EEA Dentist, with a related consideration, had been erased from the GDC register based on failure to meet the requirements set out in the Standards for the Dental Team to be sufficiently fluent in written and spoken English. 4.5. The registration process and the guidance 4.5.1. As a result of the review, we have reordered the guidance and made a number of minor changes (Appendix 1) to provide greater clarity about our requirements. In addition, we have developed a structured reference (Appendix 2) to tackle the range and varying quality of evidence supplied by applicants who submit that they have recent experience of practising in a country where English is the first language. The GPhC and the GMC have used this type of reference which must be completed by an employer, supervisor or course tutor as a means of providing assurance that an applicant is able to communicate and interact safely with patients, relatives and other healthcare professionals in English. 4.6. Reviewing the IELTS pass levels 4.6.1. Following the consultation exercise, the IELTs pass levels were increased for dental nurses and dental technicians to 7. The levels for dentists and other DCPs were not changed and remained at 7. We made a commitment that any review of language controls would include consideration of whether there was any evidence for making changes to the current requirements in relation to IELTS scores. Alongside our review of our own data, as part of the review we looked at developments and research undertaken by other health regulators to understand their experiences and any changes they may be proposing to the existing IELTs levels. 4.7. Developments and research undertaken by other health regulators 4.7.1. We met with the General Medical Council (GMC), General Pharmaceutical Council (GPhC) and the Nursing and Midwifery Council (NMC) to discuss their experiences with the IELTs levels they had set and whether there were any plans to make any changes to the existing levels. Page 7

4.8. The GMC 4.8.1. The GMC s IELTS requirements are set at slightly higher levels compared to other UK health regulators. They require a score of 7.5 overall and a skill components band of 7.0. The GMC introduced language controls in 2014 and at the same time increased their IELTs scores from 7.0 to 7.5. The increase was based on the GMC research 2 which had been commissioned to identify the appropriate IELTS score levels for applicants to their register. The GMC have no immediate plans to increase the overall level, although this remains under review. 4.8.2. The GMC has also published research 3 which looked at English language proficiency tests which might be considered comparable to IELTS. The research found that the tests most widely accepted by health professional regulators are IELTS, the Occupational English Test and the Test of English as a Foreign Language Internetbased Test. IELTs remains in the GMC s guidance as the simplest route to satisfying them of English language proficiency at the appropriate levels. 4.8.3. The GMC reported a fall in the numbers of EEA applicants to the register since the introduction of language controls, however over the same period they have experienced an increase in the number of non EEA applicants to the register. The increase is not thought to be linked to the introduction of language controls. 4.9. The NMC 4.9.1. The NMC introduced language controls in January 2016. Application packs requested before 19 January 2016, and received before 19 July 2016 were assessed under the previous rules (with no requirement to provide evidence of language proficiency for EEA applicants. The NMC experienced a surge in applications from EEA nurses ahead of the deadline). They announced last summer that they would be making changes to their IELTs requirements; under the previous system applicants were required to achieve the IELTS Academic Test at Level 7 overall and 7 in each skill component in a single sitting. The amended system now allows applicants to achieve Level 7 over two sittings. Both tests must be within six months of each other and no single score must be below 6.5 in any of the areas across both tests. As we understand it, this shift was in response to NHS staffing pressures as well as feedback from stakeholders 4.10. The GPhC 4.10.1. The GPhC introduced language controls more recently than the other regulators (November 2016). They require all applicants (pharmacists and pharmacist technicians) to attain a score of 7 overall and 7 in each skill component. Their guidance for applicants also mirrors the GMC s guidance. As the implementation has been recent there was limited impact to report. 4.11. Benchmark policies adopted by other regulators 4.11.1. The Architects Registration Board (ARB) We looked at the language policies adopted by other regulators. The Architects Registration Board (ARB) requires applicants whose first language is not English to undertake the academic IELTS certificate and achieve scores of 6.5 or above in each 2 Identifying the appropriate IELTS score levels for IMG applicants to the GMC register - http://www.gmcuk.org/identifying_the_appropriate_ielts_score_levels_for_img_applicants_to_the_gmc_register.pdf_5519 7989.pdf 3 IELTS Equivalence Research Project 2015 http://www.gmcuk.org/gmc_final_report Main_report extended Final 13May2015.pdf_63506590.pdf Page 8

of the skill components. ARB considers alternative evidence to the IELTs and applicants must complete an English Language Exemption form and provide the required supporting evidence and references. Alternatives to IELTs may include evidence that the applicant has undertaken certain courses (first and advanced degrees and other training) which have been taught and examined solely in English within prescribed timescales. 4.11.2. The Royal College of Veterinary Surgeons (RCVS) The Royal College of Veterinary Surgeons (RCVS) stipulates that veterinary surgeons wishing to practise in the UK must be able to communicate effectively with clients, including in written and spoken English. Where there are significant doubts about an applicant s language ability, they will be given the opportunity to provide additional evidence of their English language ability and the option of passing IELTS level 7 (or an equivalent English language qualification at the same level or higher). 4.11.3. The Civil Aviation Authority and the Solicitors Regulation Authority set a skills test that incorporates language proficiency testing and do not generally require a separate test for international applicants. 4.11.4. The benchmarking exercise with health and non-health regulators has shown that the levels we have set for dental professionals are broadly in line with other professional groups. 4.12. Collaboration with stakeholders 4.12.1. The GDC s development of language controls in April 2016 was permitted by UK legislation building upon a clarification of competent authority powers with the revision of the Professional Qualifications Directive. 4.12.2. Following the outcome of the UK referendum on membership of the European Union, we need to think carefully about any increase in barriers to the movement of professionals such as an increase in IELTS levels. In this regard, it would be helpful for the GDC to continue work with other stakeholders to inform our future approach to setting the appropriate IELTS which is an important part of ensuring patient safety. For example, the Faculty of Dental Surgery of the Royal College of Surgeons (FDS) England has expressed a particular interest in any future review of the IELTs levels. FDS has also developed and piloted their own test of clinical communication skills which we will give consideration to in terms of our evidence requirements. Any evidence received by them or other stakeholders in relation to the sufficiency of language controls will of course be considered as part of the ongoing review of the adequacy of our processes. 5. Conclusion 5.1. In conclusion, the FtP and other registration data gathered since the implementation of language controls shows that there has been a limited impact. Numbers of registrants applying to the register have been stable and the increased IELTS scores for dental nurses and technicians have had no bearing on the numbers of EEA applicants to the register. In terms of the implications for patient safety, the data shows that the figures where fluency in the English language has been called into question remain small across both registers. In line with the other regulators we intend to keep our guidance under review to ensure our approach to checking whether dental professionals have the required standard of English language to practise in the UK remains efficient and effective. We will continue to work with key stakeholders, particularly the FDS, to review new evidence about the IELTs scores that we set and to consider other courses that are equivalent to IELTS. Our recommendation to the Council would be to retain the existing IELTS scores for dental professionals. Page 9

6. Recommendations 6.1. The Council is asked to consider and approve the updated guidance. 7. Internal Consultation Department Registration HR Date and consultee name April 2017 a workshop was held with colleagues from registration to discuss issues arising from the process and the guidance. June 2017 Shazad Choudhry Head of EDI 8. Appendices Appendix 1 - Statutory guidance Appendix 2 - Structured reference Page 10