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UK membership of the EU brings undoubted benefits in trade, cultural development, and political stability. It also brings legislative problems in relation to the governance of the professions, particularly dentistry. While we in the UK have, through the GDC, an effective mechanism for the maintenance of standards of dental training and the level of competence of graduates in this country, we have no input into the setting and monitoring of dental educational levels in other EU member states. Nevertheless, we do have an enforceable obligation under Directive XV to accept any dental graduate from a Member State onto the Dentists Register and thus allow them the right to practise in the UK. Thus, the principle of the freedom of movement across frontiers takes precedence over all other considerations and potentially puts the public at risk.

Movements of dentists between the EEA and UK

Table 1 shows the number of graduates from EEA countries (that is EU countries plus Iceland and Norway) first registering with the GDC for each of the past 3 years. These relatively high figures are to a certain extent offset by the number of previously registered EEA dentists who are leaving the Register each year. Unfortunately, such figures are more difficult to establish but the net changes in the number of EEA dentists on the Register are evident by comparing the total EEA registrations over successive years as published in the Dentists Register (Table 2). The net increases in new registrations from EEA countries for the years 1996–1998 greatly exceed the numbers of UK dentists applying to the GDC for Certificates of Compliance (4, 17 and 11 for the years 1996, 1997 and 1998 respectively). Certificates of Compliance with the European Directives are issued by the GDC to UK citizens holding registrable first qualifications from UK dental schools intending to practise in EEA countries. They do not necessarily imply that such dentists have, in fact, migrated. The net increased registrations by EEA dentists need to be interpreted in the light of the round of closures of UK dental schools of a decade ago. The figure for the current year (218) is more than equivalent to the output of three UK dental schools, the number closed down by the Universities Funding Councils in the late 1980s. Over the 3-year period the average annual net additional registrations from the EEA was 216, equivalent to 29% of the annual new registrations from our own schools (735) averaged over the 3 years to 1997. Somewhat alarmingly, therefore, these figures also form a background to the recent announcement by the Chief Dental Officer for England (Statement to the Association of Dental Hospitals Biannual Meeting, 16 October 1998) of a further manpower review for dentistry which may have implications for the number of graduates to be aimed for nationally, and hence ultimately the number of dental schools required. As an aside, while figures for new registrations by dentists from non-EEA countries with qualifications recognised by the GDC are broadly similar to those for incoming European dentists, such dentists do not have automatic right of abode and, therefore, are not germane to this paper.

Table 1 Table 1
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Table 2 Table 2
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Educational experience and competence of EU graduates

Manpower considerations apart, it is the quality of the educational experience and the level of competence achieved on graduation by other EU Member States' dentists that is of immediate concern. While most EU graduates are no doubt competent to practise a level of dentistry commensurate with the needs and health provisions of their own country, it cannot be inferred that the provision of dental services and the expectations of communities are uniform across the whole of the EU and, therefore, that such dentists are automatically suited for practice in the UK. Moreover, few of the Member States have an independent body equivalent to the GDC to set and monitor the standards of graduates across their own schools. Indeed, the involvement of even limited outside controls on dental courses and examinations, such as through the External Examiner system, which is ubiquitous throughout the UK and Ireland, is not necessarily in place in the other Member States.

The Sectoral Directives for Medicine and Dentistry, introduced in 1978 included Directives 78/686, 687, 688/EC which aimed to coordinate training by listing the subjects for dental courses, established the mutual recognition of diplomas, and set up the Advisory Committee on the Training of Dental Practitioners. It was intended by these means to ensure the eventual attainment of common standards of training and practice in dentistry across the whole of the EU. But, has this been achieved? Do dental schools throughout Europe conform to Directive 78/687 (content of the undergraduate curriculum)? In 1997 Shanley et al.1 published the result of a questionnaire sent to all 127 of the European schools but of whom only 30 made any reply. The paper showed, even among the 30 responders, a wide disparity in curriculum and considerable departure from the syllabus within the Directive and concluded there was more evidence for divergence than convergence. However, even if the survey had shown considerable convergence of curricula, there is no means of knowing whether the level of competence on graduating from dental school, ie the ability to practise dentistry independently, is either uniform or equivalent to the standards of competence attained, for example, in the UK schools. This is not to infer that all dental graduates across the EU are of an inferior quality. Such is clearly not the case. It is simply to state that there is no means of monitoring or assuring ourselves as to the level of competence that is indeed achieved by the new graduate in each of the Member States.

Several countries have a long and well-established record of dental education and research and the levels of competence of the new graduates may in some respects exceed those of UK graduates. No other EU countries, however, have a VT scheme comparable to our own (Table 3) and it is for that reason that we cannot insist on EU graduates participating in our own schemes even were they to be made a requirement for registration. Thus non-UK EU graduates would be able to register with the GDC, without such 'additional' training.

Table 3 Table 3
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Schools in those countries where dentistry may only recently have been defined as an entity separate from medicine place a different emphasis in their undergraduate teaching with, for instance, only limited exposure of the student to direct operative dental practice on patients throughout the clinical years. Cultural conditions in several countries operate against a widespread acceptance by the public of treatment delivered by students in training, with the consequence that most undergraduate practical training has to rely on simulation by the use of manikins. Exodontia and oral surgery may figure only lightly in the clinical curriculum in those countries where caries rates are so low that dental extractions are rarely needed in dental practice.

The DENTED project

The question that arises is what should now be done to address this problem. There can be no doubt that the legislation protecting the rights of all EU dentists to practise unrestricted in any Member State is immovable and therefore other means must be found. The answer lies in persuasion, influence and peer pressure. To this end, a recent pan-European collaborative development is of signal importance. This is the DENTED Project, a Thematic Network Project (TNP) within DGXXII under the title 'Achieving Convergence in the Standards of Output of European Dental Education' (http://www.dented.org)

The DENTED Project was awarded in 1997 to Dublin School of Dentistry together with 26 partner institutions covering all the countries of the EU. Its first objective is to establish a network of European institutions involved mainly in undergraduate dental education and establish a database of information on dental education to be shared among the schools of Europe. The intention is to promote an understanding of the educational systems currently in operation in the training of dentists throughout the EU. The Project aims to promote quality improvement through self-assessment and peer discussion in the dental schools of Europe and has developed a self-assessment questionnaire. However, the most important element in DENTED is the establishment of a voluntary programme of school visitations. These will be undertaken by multi-national teams of visitors to participating schools and will allow and encourage review of the different methods of education and standards of outcome encountered in the various schools. The aim is to promote the dissemination of best practices within the participating schools. An important objective is to educate and influence the visitors as much as to highlight the strengths and weaknesses of the host school. It is important to emphasise the DENTED Project is not intended to result in the imposition of a single educational approach or a standard European curriculum for dental training.

At the recent plenary session of the Standing Conference of DENTED held in Dublin in September 1998, with representation from 40 schools throughout the EU, a protocol for site visitations was agreed. Each visit will last over 3 days and will culminate in a report which will be confidential to the visiting group and the host school. Such Reports will be constructive and highlight strengths as well as areas requiring improvement. Under DGXXII which sanctions the TNPs, there can be no question of censure of schools by the visitors. Reports could not be used, for instance, to restrict registration or rights to practice of graduates from courses considered deficient. By agreement with ADEE (Association for Dental Education in Europe) participating schools will receive certification of their involvement in the visitation process. While such certification is in no sense a kite-mark for quality, its award will encourage schools to participate in the programme. Moreover, ADEE has agreed to take over the TNP when the initial DENTED Project comes to an end in 2001. Already four DENTED visitations have taken place (Brescia, Dublin, Freiburg and Helsinki). A further ten are agreed by the year 2000 and funding from DGXXII of the EU has been allocated for a second year of operation. So far only one UK school (Liverpool) has agreed to participate.

Staff and student exchanges

Other initiatives under the SOCRATES/ ERASMUS exchange schemes in the EU, focus on staff and student exchanges. It is believed that this is a crucially important element in allowing, first of all, dental academics from schools in different countries to experience the approaches being taken by their colleagues elsewhere in Europe and, importantly, to learn from this experience when there are obvious advantages over their own systems. Student exchanges are also encouraged but, while it is often difficult for UK students to go to other countries because of language restrictions, the same is not true in reverse. For many incoming students, the advantage is overwhelmingly the opportunity to increase their hands-on experience in patient care in clinical dental training. It is hoped that eventually students so educated will cease to tolerate training programmes that are irrelevant or too heavily based on simulation rather than real clinical experience.

It is only in ways such as these, where staff and students freely move across frontiers, that we will bring about the convergence of educational methods throughout Europe to the highest possible standards and thereby ultimately justify the free movement of dental practitioners throughout the whole of Europe. And while we in the UK may also have much to learn from experiences elsewhere in Europe, we must, nevertheless, remain vigilant to ensure our patients are not inadvertently exposed to practitioners unprepared for the standards of practice in the UK. The General Dental Council's proposed recertification and performance review procedures will be equally binding on all dentists practising in the UK, irrespective of their country of origin and qualification and may ultimately provide powerful safeguards. In the meantime it behoves the UK Dental Profession to accept our European colleagues into the practice of dentistry in the UK and allow them to learn and improve where necessary by peer review and exposure to a complex system of continuing dental education and lifelong learning. In this respect the voluntary participation by 15 EU dentists in VT schemes since 1995 is wholly welcome.2

Conclusion

Certainly the numbers of incoming EU dentists are now sufficiently high and sustained (Table 1) to exercise a discernible impact on the profile of the profession in some parts of the country. It is hoped, however, that this ingress will be taken for what it is — a useful, potentially valuable adjunct rather than an excuse for the profession or politicians to re-open once more the question of the numbers of dentists in training in the UK. Our own GDC-monitored training programmes have to remain the bedrock of standards for our own new graduates and ultimately for the profession in this country. That can only be assured by the continuance of a healthy robust academic sector represented by the current number and distribution of dental schools and hospitals throughout all parts of the UK.