What’s in a word?

There are some words that UK dentistry seems to trip over more easily than most. One of them is ‘access’, and this was the source of untold pain for the Department of Health for the best part of a decade. The ‘access problem’ was consigned to history by a combination of factors – none of which, ironically enough, had much to do with the politicians and civil servants who had juggled with this political and social hot potato for so long. Interestingly enough, the previous government was careless enough to have linked two of the more recognisable banana skins into a single strapline – the ‘Quality, Access and Choice’ agenda. Of these three, ‘Choice’, should really be the least contentious, assuming of course you can define it in a way that ensures it means precisely what you want it to mean. And, as Humpty Dumpty famously added, ‘neither more nor less.’ You get access problems not when need outstrips supply, but when local demand outstrips local supply.

And, when the scale of this mismatch reaches pandemic proportions – and there are only one or two local providers left – you get choice problems, too. And when the remaining provider(s) becomes overwhelmed by the demand, quality problems are rarely far behind. The reverse does not hold true equally well. You can have outstanding quality, but access to it may be strictly limited (on cost grounds, for example) and you can have ready access to a sea of mediocrity without any real choice at all.

Interestingly enough, as far as our political masters are concerned, the point at which there is no longer deemed to be an access problem is when nobody is moaning and no queues of people are forming outside a dental surgery for a media photo opportunity. It is governments, not dentists, that create access problems and also the circumstances that make them more likely. Last time around, it took the media a little while to fathom this out but, to their credit, they got there eventually. On the other hand, only the profession can fix quality problems, although governments can certainly facilitate or impede the process.

And they have a habit of doing so, taking the credit for any and every quality improvement (some of which is well earned) but pointing the finger at dentists whenever quality falls. Which brings us conveniently to the third element of the mystic triad, Choice. We are not hearing too much about that in England any more, as the way is being prepared for the new GDS contract. Unless of course we accept that it still represents a choice when patients are told what NHS dental treatment they can have and when.

They are to get the choice of NHS treatment on specified terms and conditions, or the choice of receiving no treatment at all.

Direct access

And right on cue, our triad has re-surfaced yet again since the start of May in the shape of direct access. In case you have been on holiday in a parallel universe recently, or heavily sedated for some reason, this means that members of the public no longer need to enlist the services of a registered dentist to act as the gatekeeper of dental services, before seeing a dental hygienist or dental therapist. Given that dental hygienists and therapists were already able to own and operate dental practices and employ dentists to work in them, the GDC’s decision to allow direct access has finished off an incremental journey that has been unfolding for more than a decade, here in the UK. I say ‘here in the UK’ because we have been playing catch-up compared to certain other countries – not least, Australia, New Zealand and Canada and some states within the USA.

Advocates and supporters of direct access make their case largely on the basis that it improves both Access and Choice, primarily by widening competition and making dentistry more affordable. Opponents of direct access generally start by questioning Quality and sitting with that, raising concerns about patient safety, and they will often waste no time before questioning the Choice and Access assumptions, too.

In my day job, I have been embroiled in these discussions for well over 10 years now, and have had a ringside seat from which to witness the direct access reality show. What generally happens in the short term is – frankly – not an awful lot. Patients mostly continue to see the same hygienist or therapist they were seeing before the change, in the same surgery.

And, since they pay pretty much the same for the privilege of doing so, they may well be blissfully unaware that anything has changed at all. Taking a slightly more cynical view, hundreds, or perhaps even thousands, of hygienists and therapists will be seeing patients without a written prescription from a registered dentist who has previously examined the patient. Just like they were doing before the change. It will take time for the practical implications to sink in and, within the totality of what has been said on both sides of the argument – and believe me, feelings run pretty high – is some good sense, some complete nonsense, some propaganda and some spin, in almost equal measure.

It has been exactly the same in every other country where a similar watershed has occurred. Most of the best and worst of the supposed and predicted consequences of direct access generally don’t materialise. What does happen is the stuff in the middle. Dentists and hygienists who work closely together under the same roof will mostly continue to do so, but some of the practical obstacles are removed for the benefit of all parties (including patients).


Will the Office of Fair Trading be turning cartwheels of ecstasy as consumers of dental care and treatment see prices tumbling, with new dentist-free practices opening up on every street corner and remote village green, offering bargain basement prices and free iPhones with every third scaling? I don’t think so.

There may be a backflip or two in evidence up the side corridors of Richmond House because the Department of Health gets everything it wanted from the GDC to facilitate the use of dental nurses in the delivery of public health measures (including fluoride varnish applications and other such interventions that had hitherto needed the direction and supervision of a registered dentist). I don’t think anyone was terribly surprised at this outcome. There is, however, one big risk that most observers have overlooked or glossed over. When the margins between different types of healthcare providers become blurred as a matter of deliberate policy, it makes the assumption that members of the public will know and understand the difference.

When everyone appears to be wearing the same leotard and offering the same service, you need to look quite closely and ask the right questions in order to be sure of what you are getting. The door has been left wide open for members of the public to argue – as they have done elsewhere – that they had never realised that their treating  clinician was not a dentist, and consequently their consent was not valid in the first place. If I jump on a plane and after it crashes spectacularly, I discover the pilot with gold braid from wrist to armpit was, in fact, a baggage handler, I am going to be pretty fed up. Posthumously, I grant you – but pretty fed up nonetheless.


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