Will Direct access to dental care professionals revolutionise the delivery of dental care in the United Kingdom?
This is the first of a 2-part article which will discuss:
- Part 1 – Introduction and Benefits of Direct Access
Part 2 – Drawbacks of Direct Access and Conclusion
The introduction of “direct access” dentistry has recently become one of the most controversially discussed subjects amongst dental professionals in the United Kingdom. This essay will discuss whether direct access to delivery of dental care is truly revolutionising to the healthcare system. To scrutinise the topic, this essay will take into account important facts and figures, and explore the constituent elements of the concept, the system’s history, the basis of the decision taken, potential implications and various organisations’ reactions to direct access. This essay also aims at increasing public awareness regarding the provision of dental services within our society, as after all we are all part of this change.
To understand our focus, we need to ask ourselves, what does direct access imply to the delivery of dental care in the UK? On 1st May 2013, the General Dental Council (GDC), which is the UK’s dental team regulatory body in accordance with The Dentists Act 1984, has agreed to lift the ban for Dental Care Professionals (DCP), such as dental hygienists and therapists, to directly treat patients across England and Wales. The GDC1 defines direct access as “giving patients the option to see a dental care professional (DCP) without having first seen a dentist and without a prescription from a dentist”. Traditionally, dentists had to prescribe and refer patients to DCPs for treatments2 as it was not permissible for patients to be seen by a DCPs without being seen first by a dentist. Direct access3 has now made this become obsolete, allowing dental hygienists and therapists to treat directly to their full scope of practice, orthodontic therapists to conduct IOTN index for orthodontic treatment need and dental nurses to participate in oral health awareness campaigns. Clinical dental technicians can continue to work with edentulous patients for the provision and maintenance of full dentures. DCPs can additionally now run DCP-only dental practices, with dentists excluded from the team. As per current legislation1, 4, 5 however, IR(ME)R 2000 training must be completed to conduct radiography in the UK while no changes have been made yet to entitle DCPs to prescribe local anaesthesia or undertake tooth whitening directly.
The GDC’s decision to lift direct access barriers to the delivery of dental care by DCPs, was made after the GDC’s Task and Finish Group concluded responses to several consultations and surveys, including the 2013 Rapid Review. The decision6 was also highly influenced by the non-ministerial Office of Fair Trading’s (OFT) 2012 Report, which recommends direct access dentistry. The OFT7, 8 produced a recommendations package, in which it criticised dentists’ lack of transparency in relation to differentiating NHS and private treatment fees to patients, calling for “urgent reforms” to the “new” 2006 NHS dental contact. During an interview7 with the BBC, Mr John Fingleton, Chief Executive of the OFT, both asserted this and recommended direct access.
Statistically, the OFT found that nearly £6bn was spent on dental treatment in 2009-10, of which 42% was spent on private treatment compared to 58% spent via the subsidised NHS system7. In 2009, it is reported9, 10 that the England and Wales NHS contract, which is criticised by Welsh dentists11, has led to more than 1m fewer patients treated by NHS dentists within 2 years after its introduction. Furthermore, around 1,000 dentists abandoned the NHS contract for private dentistry while only a minority were appealed to uptake NHS employment. It is yet strange to find contradicting reactions11 to the negative views the NHS had to the delivery of dental care services prior to direct access. For example, in 2010, the Patients Association, a healthcare charity, stated that “innovative” NHS management had helped substantially improve access to NHS dentists for patients in Wales.
The GDC reported13 that NHS law is a limiting obstacle to the delivery of dental public healthcare. In England and Wales, the current legislation has not yet permitted hygienists and therapists to hold subsidised NHS contracts similar to dentists, to provide NHS-fee treatments. Scotland and Northern Ireland would need to change their primary legislation to validate direct access equivalently, to approve NHS contracts for DCPs. Also as per current regulation, patients must first be seen by an NHS contractor or a performer dentist for initial diagnosis and treatment planning be able to access DCPs freely. In practical terms, direct access to DCPs is therefore currently restricted to private rather than public NHS dentistry.
It is important to justify direct access based on benefits it brings about to the delivery of dental care for it to be deemed revolusionising. It has always been suggested that dentistry is a mix of business and healthcare provision, considering that treatment costs hugely influence the clinical and governing decision-making processes. A dental survey14 has found that more than 25% of adult patients said the type of dental treatment plan they chose was determined by the treatment cost and just under 20% said they postponed treatment for the same reason. DCPs could potentially reduce dental unit expenses through the provision of low-cost dental services, and also through the nature of their public preventive work which limits disease progression, preventing costly treatments in the long-term13, 15, 16.
In practice, current statistics13, 17 show that only 10% of patients who tried to approach an NHS dentist managed to book an appointment with the first dentist they approached, even though 87% booked one eventually. Empowering dental hygienists and therapists to operate their own surgeries will increase the healthcare providers to patients ratio. Patients4 also believe it is unnecessary for NHS dentists to regularly see patients who only need very initial basic management covered by the scope of practice of DCPs. There is a strong evidence18 that direct access will improve the overall delivery and accessibility to dental healthcare and therefore disburden the backlog that has been a concern in the UK since mid 1990s14.
Psychologically, it is also believed that dental treatment and associated costs exacerbate dental anxiety. 12% of dentate adults experienced anxiety even though 80% stated they were happy with their treatment14. Direct access will outstretch the delivery of dental care to a wider range of the public; DCPs provide low-cost non-invasive non-surgical treatments, and are perceived to be the tailor-made catalysts for anxious patients to return back on to dental healthcare system. DCPs are also as equally supportive as dentists in handling smoking cessation, diabetes, child abuse and domestic violence scenarios19. Additionally, DCPs themselves, will feel more valuable and respected as associates, responsible to confidently provide the healthcare they are trained for without dentists’ approvals20, 21.
- General Dental Council. Direct Access Q&As. https://www.gdc-uk.org/Dentalprofessionals/Standards/Pages/directaccessqas.aspx (accessed 4 April 2014).
- General Dental Council. Direct Access. https://www.gdc-uk.org/Dentalprofessionals/Standards/Pages/Direct-Access.aspx (accessed 4 April 2014).
- General Dental Council. Patient Safety at the heart of the decision over Direct Access. http://www.gdc-uk.org/newsandpublications/pressreleases/pages/patient-safety-at-the-heart-of-decision-over-direct-access.aspx (accessed 6 April 2014).
- Department of Health. The Ionising Radiation (Medical Exposure) Radiation 2000. http://www.legislation.gov.uk/uksi/2000/1059/regulation/11/made (accessed 25 April 2014).
- Department of Health. The Human Medicines Regulations 2012. http://www.legislation.gov.uk/uksi/2012/1916/contents/made (accessed 15 April 2014).
- The Council. Update on GDC response to the OFT market study into Dentistry. GDC. Item 24, 2012.
- Dentistry “needs urgent reform” says OFT. The BBC. 29 May 2012. http://www.bbc.co.uk/news/business-18233619 (accessed 6 April 2014).
- Public Publication. The private dentistry market in the UK. London: Office of Fair Trading. Report Number: OFT630. 2003.
- Q&A NHS Dentistry. The BBC. 18 May 2009. http://news.bbc.co.uk/1/hi/health/8056345.stm (accessed 15 April 2014).
- Nigel Triggle. Elderly “suffer” over dental care. The BBC. 30 Oct 2008. http://news.bbc.co.uk/1/hi/health/7697879.stm (accessed 15 April 2014).
- NHS dentistry “set back 20 years”. The BBC. 19 Feb 2008. http://news.bbc.co.uk/1/hi/wales/7251246.stm (accessed 15 April 2014).
- Access to NHS dentists “improves substantially”. The BBC. 11 March 2010. http://news.bbc.co.uk/1/hi/wales/wales_politics/8560318.stm (accessed 15 April 2014).
- The Council. Direct Access. General Dental Council. Item 3, 2013.
- Nigel Nuttall, Ruth Freeman, Colin Beavan-Seymour, Kirsty Hill. Access and barriers to care – a report from the Adult Dental Health Survey 2009. Health and Social Care Information Centre. Report Number: 8. 2011.
- A. Northcott, P. Brocklehurst et al. Direct access: lessons learnt from the Netherlands. Br Dent J. 2013;215, 607 – 610. http://www.nature.com/bdj/journal/v215/n12/full/sj.bdj.2013.1193.html (accessed 25 April 2014).
- The Institute. Patient research into Direct Access- Report for the General Dental Council. Ipsos MORI Social Research Institute. 2013. http://www.gdc-uk.org/Newsandpublications/research/Documents/Patient%20Research%20into%20Direct%20Acces s.pdf (accessed 25 April 2014).
- Jimmy Steele, Ian O’ Sullivan. Executive Summary: Adult Dental Health Survey 2009. Health and Social Care Information Centre. Report Number: 1. 2011.
- Nicola P T Innes, Dafydd J P Evans. Evidence of improved access to dental care with direct access arrangements. Evidence Based Dentistry. 2013; 14, 36 – 37. http://www.nature.com/ebd/journal/v14/n2/abs/6400926a.html (accessed 25 April 2014).
- S. Turner, S. Tripathee, S. MacGillivray. Direct access to DCPs: what are the potential risks and benefits?. Brit Dent J. 2013;215, 577-582. http://www.nature.com/bdj/journal/v215/n11/full/sj.bdj.2013.1145.html?WT.mc_id=TWT_The_BDJ (accessed 25 April 2014).
- Julie Rosse. Addressing the big question of direct access at the Dentistry Show. BSDHT. 2013.
- S. Turner, M. K. Ross, R. J. Ibbetson. Dental hygienists and therapists: how much professional autonomy do they have? How much do they want? Results from a UK survey. Br Dent J. 2011; E16. http://www.nature.com/bdj/journal/v210/n10/abs/sj.bdj.2011.387.html (accessed 25 April 2014).