Animal Farm

When down on the farm, rule one is ‘always remember to shut the gate’. The whole purpose of gates is to allow some things to pass through, while effectively excluding others – or at least, to impose some control over the rights of passage.

On the other hand, cattle grids are the result of some ‘outside-the-box’ thinking, and they have a similar effect without the inconvenience to regular (approved) traffic.
Rule one has always applied where the control of access to primary health care is concerned, with the general medical or dental practitioner having been appointed the custodian of the gate. Patients (other than in an emergency) access healthcare through their GP/GDP and this is the accepted route to secondary and tertiary care. But, in medicine, this model has been
changing and these days you need to have a pretty good reason to get an audience with your GP, rather than being administered to by one of the platoons of nurse practitioners, practice nurses, nurses and other health professionals.

Interestingly enough, Bar Direct removed the corresponding time-honoured role of the solicitor as the gatekeeper for access to the Bar. Similarly, law and order is increasingly ‘fronted’ by Community Support Officers rather than police officers. The present situation in dentistry seems awkward and out of step, and the traditional ‘gatekeeper’ role of the GDP is coming under threat. As things stand, the practitioner is left to decide when it is appropriate to treat a patient personally, and when the circumstances make it appropriate to refer the patient up or down the dental feeding chain to a DCP or specialist. It has been assumed thus far that all registered dentists are competent, by virtue of their training and qualifications, to discharge this ‘gatekeeper’ role.

But hygienists, therapists, technicians and dental nurses still need a dentist to ‘screen’ the patient and provide the clinical direction. For clinical dental technicians, the gate is ajar and patients can consult them directly.

Dental specialists in many countries cannot be accessed directly by the public, while in the UK they can be accessed by patients either directly, or upon referral from a GDP ‘gatekeeper’ or specialist colleague.

In UK dentistry, the pendulum has already swung twice in quick succession and it remains to be seen whether it will swing again and, if so, in which direction. I suspect it has not yet come to rest, especially if Government needs to make NHS services more accessible and/or more
cost-effective. An expanded duty DCP workforce is of little use to the Government if the dentists still hold the keys to the gate.


Nobody was quite prepared, I think, for the sudden sense of liberation (and lack of ‘anchor points’) that was created by the initial introduction of the ‘competency’ approach to scope of practice, whereby all dental registrants were simply expected to practise within the limits of their training, competence and physical ability, sweeping away the familiar lists of permitted duties at the same time. So the second swing of the pendulum was to create new lists firstly of what each group of registrants (including dentists) could ‘normally’ do, and what additional duties they might be able to carry out after receiving additional training.

All this makes the assumption that training is the sole determinant of competence. I don’t actually accept this for a moment. Do we really believe that every registered dentist is a fantastic gatekeeper, consistently exercising impeccable judgement about what to do personally, when to enlist the help and support of a hygienist or therapist, technician or nurse, and when to call in the heavy artillery of a recognised specialist or a more experienced colleague? And do we also believe that there is no circumstance in which an experienced hygienist, therapist, technician or dental nurse could ever deliver an adequate ‘gatekeeper’ service? If so, we are delusional and should get out more.

In reality, as George Orwell so famously pointed out three years before the start of the NHS, ‘All animals are equal, but some animals are more equal than others’.  The level playing field of Standards for Dental Professionals – and the ‘one size fits all’ approach to so many contemporary dental conundrums – is not really helping at all, because it attempts to paper over the designed-in and inevitable inconsistencies in competence, in training, in experience and in personal judgement. The groups of dental registrants are not equal, and nor are those within them.

The most recent twist in the bleaching/tooth whitening fiasco was the recommendation of the EU’s Scientific Committee on Consumer Products (SCCP) that the supply of products containing or releasing 0.1% to 6% hydrogen peroxide might be permitted under future amendments to the Directive and local regulations, subject to the patient being examined by a dentist who would carry out a risk assessment. Thereafter, a hygienist or therapist could carry out the procedure (if the dentist thought it appropriate) – but only a dentist could carry out the risk assessment that preceded it.

This is actually a good example of where some clarity about who could or should be the ‘gatekeeper’, and under what circumstances, is positively helpful – whether or not you happen to agree with where the SCCP has chosen to place the bar.

Meanwhile, an experienced hygienist cannot officially ‘diagnose’ periodontal disease and set about treating it, without first consulting a registered dentist. With some patients, Blind Freddie could ‘diagnose’ the presence of periodontal disease at 50 paces. When a patient’s anterior teeth are leaning earnestly towards you and jostling for position while you are taking a medical history, it is a bit of a giveaway. Everyone is committed to the competency-based approach, it seems, but only after a diagnosis has been made. How clever is that?

Rule one applies to dentistry every bit as much as it does to farming. ‘Shut the gate’ appears to have become the default maxim at the interface between dentists and DCPs and even between specialists and generalists. The gate-shutting and ladder-raising at the time of the introduction of specialist lists was not one of the profession’s finest hours. And even today, one discovers individuals who find themselves trapped on a training pathway that no longer ends with a rainbow containing a CSST.

Which brings us conveniently to rule two. A question often asked by practitioners at moments when their diagnostic monopoly is coming under pressure, is that of ‘What happens when someone other than a dentist is clearly competent to act as a “gatekeeper”, at least in some clinical situations?  The answer (and hence, rule two) is of course, ‘In these situations, please refer to rule one’.

It rather looks as if all dental registrants are equal, but some registrants are more equal than others. Someone should write a book about it.

• Kevin Lewis is speaking at the Private Dentistry 2008 National Conference on Thursday
27 November at The Hotel Russell, London. The event will provide you with the tools to develop your practice and make it more profitable by bringing you and your team fully up to date on the latest developments in private dentistry. For further information and to book your places, please call 0800 371652 or visit the website at

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