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:
Cons of Direct Access
Having praised direct access, it is definitely worthwhile for us to question any potential negative implications direct access may create to the delivery of dental care. One particular concern is the possession of patients records. The GDC1 has resolved this, stating that all dental professionals are responsible and if a patient is to be referred then relevant clinical information, including radiographic copies, should be attached. Formal communication channels must be in place between the registrants to ensure patients’ safety. Dental hygienists and therapists incapability to diagnose conditions such as oral cancer and mucosal disorders is bordering onto the neglect of patients’ rights to proper treatment19, 22. There is also evidence19 of poor specificity, over-referral and unnecessary consultations caused by referrals by DCPs compared to dentists, which impairs the dynamics of healthcare delivery system. Additionally, patients15 have reported increased confusion as to which dental professional to consult when in need; in terms of roles and the availability of direct access services. Some argue that It has become difficult for new dentists to enter market and good dentists to expand within the NHS. Business competition has soared that calls have been made for dentists to up-skill themselves as their basic work can be taken away courtesy of direct access23.
Dental organisations shared mixed statements24 regarding the concept of direct access to the delivery of dental care in the UK. The British Society of Dental Hygiene and Therapy (BSDHT) greatly welcomed the changes and tweeted that the adoption of the decision was ‘fabulous news”. The Clinical Dental Technicians Alumni said that direct access was “a huge step forward”. The British Association of Dental Nurses (BADN) was “pleased” that dental nurses will now be able to make full use of their qualifications, but reiterated that they need to be fully trained, competent, and indemnified for tasks they undertake.
On the other hand, the British Dental Association (BDA)25, 26 representing 19000 dentists and 4000 students, was strongly against the introduction of direct access. It believes that the GDC’s decision was misguided, financially based and undermines best practice in the delivery of dental care to the patient. It launched a campaign- “Speak up for Dentistry” to encourage dentists to submit their concerns to the GDC regarding direct access. Dr Judith Husband24, Chair of the BDA’s Education, Ethics and the Dental Team Committee, said direct access “weakens teamworking in dentistry”.
The Department of Health, on behalf of the Government of England, although supportive of direct access, seems to be more concerned about the synergy between the NHS and private dentistry complaint systems. A new remuneration concept of “Any Qualified Providor” for NHS Dentistry is to be considered to fit the changes27. Welsh devolved Government’s Minister for Health and Social Services has been asked to approve pilot cost effectiveness studies in dental services in Betsi Cadwaldwr and Hywel Dda, to assess the impact to community healthcare delivery28. Dental Protection Ltd UK29, a professional indemnity organisation, states that direct access is more like an opportunity to open practices and promote business as it will not change what competent DCPs already do. Although it welcomed the move, it stated that there is always potential for new risks to emerge, and will keep the situation under close review. The Dental Schools Council has stated that none of the evidence raised patients’ safety concerns and responded30 to the GDC’s Rapid Review 2013 consultation to facilitate dental public health intervention. Other dental charities, for example Heart Your Smile, are currently monitoring direct access and have left the discussion open for the public to discuss.
The GDC register31 shows that dental hygienists make up 6% while dental therapists 2% of total registrants. As it is achievable to archive such relatively small numbers, and as a suggestion to narrow the gap, I believe it will be very helpful if the GDC keeps a record of those DCPs practising via direct access. Despite the GDC’s1 claims of administrative and financial burdens precipitated, such documentation not only will aid patients to confidently choose suitably qualified dental healthcare providers, but also be an invaluable tool for dentists, and DCPs themselves, to facilitate inter-registrant communication and multidisciplinary healthcare delivery.
Dentists and DCPs are constantly being reshaped differently into dentistry, as the UK government continues to investigate cheaper alternatives to the delivery of dental public healthcare32. Reviewing the above literature, it is clear that the most problematic relationship detected is the conflict between the vested and professional interests of different professional associations to fulfill their own interests- a comparable scenario similarly observed15 in Holland for the same cause. Nevertheless, confidence levels in the high standard of care and levels of satisfaction that patients expect and report in our communities must be predominantly maintained17. There are proposed benefits and risks, but the implications of direct access to DCPs on the delivery of dental care cannot be supported by long-term evidence. The GDC1 itself admits uncertainty as to how many DCPs, out of their relatively small community, will embrace direct access. Therefore, based on the analysis of available quantitative and qualitative appraisals, I would personally weigh direct access as being evolutionary, rather than revolutionary, to the delivery of dental public health services here across the UK.
- 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).
- A. C. L. Holden. No to direct access. Bri Dent J. 2012;212, 355 – 356. http://www.nature.com/bdj/journal/v212/n8/full/sj.bdj.2012.321.html (accessed 25 April 2014).
- Julie Bissett. Business guru warns “dentist’s work” may be at risk from DH&Ts. Dental Hygiene & Therapy. March 12 2012. http://dentalhygienetherapy.co.uk/oral-health-news/business-guru-warans-dentists-work-may-be-at-risk-from-dhts/ (accessed 25 April 2014).
- News. GDC removes barrier to direct access. Vital. 2013; 10, 6. http://www.nature.com/vital/journal/v10/n3/full/vital1670.html (accessed 25 April 2014).
- News. GDC announces controversial decision on direct access. Brit Dent J. 2013; 214, 379. http://www.nature.com/bdj/journal/v214/n8/full/sj.bdj.2013.390.html (accessed 25 April 2014).
- Steve Turner , Sheela Tripathee, Steve MacGillivray. Benefits and risks of direct access to treatment by dental care professionals: A rapid evidence review. GDC. Final report. 2012.
- DH / Dental Services / MPI. Government Response to the Office of Fair Trading Market Study into Dentistry. Gov of England. Report. 2012.
- Direct access service pilot approved in Wales. Brit Dent J. 2013; 215, 545. http://www.nature.com/bdj/journal/v215/n11/full/sj.bdj.2013.1154.html (accessed 25 April 2014).
- Dental Protection. Dento-legal FAQs arising from Direct Access. http://www.dentalprotection.org/uk/briefing-documents/direct_access_FAQs (accessed 25 April 2014).
- Dental Schools Council. A proposal for consultation- Background, proposal and consultation questions. GDC. Report. 2012.
- GDC registrant numbers reach record high. GDC. 5 July 2011. http://www.gdc-uk.org/Newsandpublications/Pressreleases/Pages/GDC-registrant-numbers-reach-record-high.aspx. (accessed 15 April 2014).
- Foster, Joanne. Dental undergraduate team-based learning and clinical integration and its impact on knowledge and attitudes. BSc dissertation, University of Portsmouth; 2013.