The fun to be had from the 'parlour' game Consequences relies on the randomness of the story that is created by a series of different minds, as well as the security that it is only make-believe. In contrast, the seriousness of real life consequences is far more weighty and is sometimes dictated by the fact that the apparent solution does not address the problem that was originally identified. Such is the case with the issue of the public's ability to have direct access (DA) to dental care professionals (DCPs) as recently agreed by the General Dental Council (GDC).

This trail of consequences began with the Office of Fair Trading's (OFT) report in 2012 into the 'dentistry market' (the italics are mine and I use them to emphasise the philosophical stating point of this exercise). On publication of the report the OFT's press release summarised its findings thus: 'The report also raises concerns about continued restrictions preventing patients from directly accessing dental care professionals, such as hygienists, without a referral from a dentist. The OFT considers these restrictions to be unjustified and likely to reduce patient choice and dampen competition.'

The consequence of this was that the government in England, eager to leap on anything that seemed to champion consumer choice and lower prices prodded the GDC (a body now appointed through government channels) to look into the matter and report back. Dutifully following its instructions the GDC launched a consultation, without ever asking whether the proposals were in the interests of oral health, which culminated in its recent decision to permit DA to all DCPs except clinical dental technicians within certain circumstances. What is striking, however, is that the GDC announced it is to 'remove its barrier to direct access for some dental care professionals after considering the impact on patient safety.' No comment, one notes, on either of the OFT's objectives of increasing patient choice and/or improving competition.

Confusion and conflict

So, what are the consequences of this? For the OFT it is job done. For the government it has, in political rhetoric, made the necessary steps in paving the way for improved patient choice and increased competition. For the GDC it has exercised its regulatory duty so its members (shortly to be replaced anyway by an even smaller council of a mere 12 appointed members – six lay and six professional) can sleep soundly. For the rest of us, patients and professionals, the confusion begins.

To be blunt, does anyone know what this actually means in practical terms? I was rounded upon after my previous editorial on the subject for suggesting that this would mean DCPs seeking independent practice, being informed that this was already possible as DCPs could effectively own practices as the law stands (slightly missing my point, but never mind).1 So does this make independent practice more likely? If not, then under what arrangements does the DCP to whom the patient has direct access stay within the practice and the dental team? I am not trying to be perverse, I genuinely am not sure whether a patient will have the knowledge to approach the reception desk and ask to see a dental therapist instead of a dentist; as reflected in a recent paper in this journal.2

The real sadness of this situation to date, and I am hopeful that in the way all of us involved in dentistry are invariably practically minded to make things work even if they seem hopelessly against the odds, is that it can be perceived as setting, in particular, dentist against hygienist and therapist and vice versa. Given that we have all variously spent the last few years building teams and for the most part appreciating how this positively affects patient care, driving a rift through this harmony is unnecessarily disruptive.

Additionally, there seems to be more than a whiff of indecent haste about the activity. To begin on 1 May 2013, hardly one month after the GDC vote, is a faster move than most government departments witness in a lifetime. Surely some thought might have gone into how this might integrate into the new NHS contract as it is being assembled from the various components of the pilot projects underway for a time period which might on the contrary be described as indecently drawn out. How, in any event does DA work with Units of Dental Activity? If it is in effect only 'private' DA does this mean that the OFT's patient choice is between which is the lowest private fee? I suppose that would be competition.

At the end of a game of Consequences, neatly concluded as the last fold of paper is unfurled, the jolly participants are treated to 'what the world said'. At the current stage of this course of consequences, which is far from concluded merrily or otherwise, we the players might speculate that the world asks why, and what on earth does it actually have to do with improving oral health?