Will the government's long-awaited strategy for dentistry really enable everyone to have acess to an NHS dentist by next year? And isn't it time to tackle dentists' restrictive practices, ask Jean Gorham and John Galloway

On 15 September, the government issued its long-awaited strategy, Modernising NHS Dentistry - implementing the NHS plan.1 In his foreword, the health secretary said that developing dental services in England would be consistent with, and a core part of, the NHS plan.

This strategy was published just six weeks after John Renshaw, chair of the British Dental Association's executive board, in a letter to The Times, referred to dentistry as a 'semi-detached part of the service' and called on the government to recognise dentistry and dentists as an integral part of the NHS.

Does the new strategy go any way towards meeting his concerns? Can it deliver prime minister Tony Blair's promise at last year's Labour Party conference that everyone in the UK would be able to have access to an NHS dentist within two years?

2Does it allay suspicions that despite assertions to the contrary, what is actually in mind is not strengthening dentistry in the NHS, but detaching it altogether? In short, is the strategy imaginative enough in its vision of a revitalised dental service, and robust enough to dismantle the barriers to realising that vision?

In the Independent on Sunday on 13 August, John Renshaw argued that the problems of NHS dentistry were caused by underfunding and could be cured only by hard cash.More money might possibly stop the rot in the short term, and the government strategy is offering more, although it is not clear how much of this is really new funding and not old money with a new spin:£4m is proposed immediately to enable dentists to expand their practices, and a further£35m in 2001-02 for modernisation of NHS practices and equipment.

Successive governments have failed to address the way NHS dentistry is funded. The system has remained virtually unchanged since the NHS started in 1948.The constraints placed on the way dentistry can be delivered by an outmoded regulatory framework remain in place.

The result is under-investment, inequality of opportunity and restrictive practice. Since the mid-1990s there has been a gradual move towards private practice, which the BDA now estimates provides about one-third of the country's dental treatment.

The number of adults registered with the general dental services for NHS treatment has fallen since 1995 from 22 million to 18 million. It is difficult to see that£18m in loyalty payments to NHS dentists will do much to resist the pull of£400m in private dentistry, or to attract back dentists who have already moved.

Improving access to dental care is one of the strategy's main themes. The role of NHS Direct will be expanded to act as a gateway to all NHS dentistry. It will provide up-to-date advice to callers about where and how they can find an NHS dentist and dental services. This should provide a more patient-centred approach and will remove some of the barriers that people now experience when they wish to find an NHS dentist. There are plans to expand the number of dental access centres and personal dental services schemes, particularly in areas where access to care is a problem.

Significantly, for the first time, every health authority will be accountable for the delivery of a strategy for dentistry in its area. But the funding for the general dental services budget is held nationally and administered by the Dental Practice Board. It reimburses dentists for the NHS treatment they provide. Thus HAs will still have no control over the work these dentists provide nor the patients they see. The strategy does not address this issue, nor does it provide any real solution to persuading dentists to work in areas where there are few NHS dentists. The proposals for four new vocational dental training schemes will do little to improve the gap between services and needs.

The term 'NHS dentist'is misleading. Only a relatively small number of dentists are employed by the NHS, those who work in the community and hospital dental services making up less than 20 per cent of the total number of practising dentists. To most people, an NHS dentist means a dentist working in a high street practice. These dentists, with few exceptions, are not NHS employees but carry out treatment as independent contractors. Some, although not necessarily all, of the treatment they provide is for the NHS. Even when it is, most patients pay up to 80 per cent of the costs of their treatment and will continue to do so although it may become easier to gain approval for more complex treatments. Dentistry is therefore out of line with one of the NHS's founding principles of free-at-the-point-of-access, and has been since 1950.This aspect of the NHS plan's first core principle of access depending on clinical need, not ability to pay, will not be applied in dentistry.

More important than assessing the availability of NHS dentistry by the number of patients registered is to judge the strategy in terms of the NHS plan's third core principle of meeting the needs and preferences of patients, their families and carers.

Whereas anyone has a right to be on a GP's list, and the NHS organises doctors and practices so that this can be achieved, this is not true for dentists. The strategy acknowledges for the first time that those people who do not want to register as regular attenders should not be disadvantaged for getting routine dental care. It also suggests that dentists have a responsibility to assess patients' needs rather more imaginatively than through an inflexible routine of six-monthly visits.

Another major difference is that GPs can only establish practices with local approval, and cannot therefore practise where they like. Dentists, however, can practise exactly where they wish, which in turn affects where dental treatment is available.They also select the patients on their lists and decide what care they will carry out as NHS treatment - within a single course of a patient's treatment some may be carried out as NHS care and some as private.

NHS Direct should simplify the labyrinth surrounding dental treatment.

The proposed new treatment plans where both NHS and private care have to be described are a welcome move.Clinical governance will also be extended to general dental practice, which will make dentists responsible for health and safety issues and continuing professional development and updating of skills for their practice staff.

The government has reaffirmed its commitment to skills-mix in the NHS; a principle embodied in the title of the workforce planning consultation document, A Health Service of all the Talents.

The NHS plan condemns 'old-fashioned demarcations'.The dental strategy emphasises the role of the whole dental team.It endorses the General Dental Council's proposals to extend statutory registration to dental nurses and dental technicians and to extend the roles of dental therapists and dental hygienists.And it introduces new categories of orthodontic assistants and clinical dental technicians.But the 1984 Dentists Act denies equality of opportunity and supports restrictive practice (see box on previous page).Unless and until it is fundamentally changed, many of these extremely attractive proposals are meaningless.

Dentists are not only the gate-keepers to accessing dental care, but they also have complete control over delegating any treatment to other members of the dental team, and receiving patients'fees, limiting patients' choice and keeping costs high.

There is evidence in other countries that patients can gain access to dental care by a variety of routes with benefits to their oral health and with no detriment to their safety.Access to treatment through clinical technicians, dental hygienists or therapists, with patients seeing dentists only when necessary, has the advantage of cutting out routine and often unnecessary payment to the most expensive member of the dental team.

Dental hygienists and therapists are already taught to recognise oral and dental pathology.The GDC's proposal to retain the regulation that the professions complementary to dentistry can only work to a dentist's prescription results in a built-in cost to treatment that in some cases only benefits dentists.It also maintains dentists'control of the practice of dentistry.

One of the more unusual provisions of the Dentists Act is that it restricts the employment of dental therapists 'to the NHS'.In this context NHS is the hospital and community dental services.The purpose is to prevent dental therapists from working in general dental practice.This would appear not only to be a denial of equal opportunity, but impedes any plans to increase access to treatment as dental therapists could deliver 50 to 60 per cent of the treatment now being paid by the Dental Practice Board in the GDS.Last April, on the advice of the Department of Health, the Privy Council refused the GDC's request to remove the block on dental therapists working in the GDS.

3In a welcome volte-face, the dental strategy now acknowledges the potential importance of the contribution of dental therapists in increasing the availability of care and proposes to review the position.What the strategy does not say, however, is that there are no more than 400 dental therapists on the GDC's roll and fewer than 50 are trained each year.

Again the Dentists Act is the key.The GDC does not allow training to take place anywhere other than the recognised dental authorities, which in practice means dental hospitals and dental schools.And the Dentists Act specifically states that training of dental therapists and dental hygienists must not be to the detriment of dental undergraduate training.

Since the publication of the 1993 Nuffield report, The Education and Training of Personnel Auxiliary to Dentistry, there have been continual calls for reform of the 1984 Dentists Act to allow dentistry to take advantage of skills-mix to improve the availability of care.

4The provisions of the 1999 Health Act enable the government to address this and override professional monopoly in the interests of patient care.The NHS plan has announced the intention to strengthen regulation and develop common approaches.The strategy signals the need for the Dentists Act to be changed for any number of reasons, but gives no indication when this may happen.And timing is of course crucial.

The new chief dental officer, Dame Margaret Seward, with a brief to implement the strategy, is in post for only one year in the first instance.Are we to take it that the possibility of legislative change in the short term is on the cards? The dental strategy offers the way forward but withholds the means.

An exclusive body The GDC regulates the practice of dentistry by administering the 1984 Dentists Act.The GDC is, however, not merely the statutory regulatory body for dentists (the dental equivalent of the General Medical Council), it also looks after dental hygienists and dental therapists whose scope of clinical practice is included in the Dentists Act and made explicit in the dental auxiliaries regulations.

The GDC is unique among regulatory bodies and sees itself as the only possible regulatory body that can extend skills-mix in dentistry and regulate it.

But equally significant in its implications for the availability of dental care is that the GDC also regulates the business of dentistry, in particular limiting those who can legally receive payment for dental care to dentists.

In practice this means there is only one way to access dental care: through dentists.

If you cannot find a dentist and persuade him or her to see you, you cannot obtain care.

In many other countries, Australia, New Zealand and Canada for instance, treatment can be obtained directly from other members of the dental team - dental hygienists or clinical dental technicians.

It is interesting how a regulatory body can interpret its role to protect patients.In effect the law probably under-protects patients from dentists, but over-protects them from the professionals complementary to dentistry.Registered dentists are able to practise dentistry with little restriction, while the permitted work of dental hygienists and dental therapists is specified in considerable detail.

The strategy does not suggest looking at skills-mix any more widely than the GDC's own proposals but reinforces the controlling position of dentists.

Under the Dentists Act, anyone apart from dentists who provides and fits dentures is carrying out the practice of dentistry illegally. Yet in many countries clinical dental technicians, sometimes called denturists, carry out this work legally with no detriment to patients.

In the UK, even though this practice is illegal, there is clearly considerable public demand and satisfaction.

Furthermore, few successful prosecutions can be initiated by the GDC.It appears indefensible in the interests of protection of the public that clinical dental technicians remain outside the law - which will have to be changed to permit them to practise.

The Department of Health will now have to address this.

There is little doubt that the stumbling block will be the business of dentistry and the unwillingness of many dentists to allow anyone else to carry it out.

REFERENCES

1 Modernising NHS Dentistry: implementing the NHS plan. Department of Health. September 2000.

2 Labour Party Conference Speech.28 September 1999.

3 Letter from Privy Council to GDC registrar.6 April 2000.

4 Education and Training of the Personnel Auxiliary to Dentistry. Report to the Nuffield Foundation. September 1993.