There are times in life when we are introduced to concepts that are new to us and which are incredibly exciting. Exciting primarily because they cause us to think about things differently, things, which until that point we had regarded as being set in a certain way. Darwin's theory of the survival of the fittest might be one such example, or for me the explanation of the binary way of denoting numbers, thereby allowing the possibility, combined with electronic theory, of creating computers.

In the realm of such weighty matters, it might therefore seem quite small fry to equate a similar moment of revelation when someone first clarified the notion of 'third-party' payers in terms of dental care. It is not a difficult concept, and yet in its own fashion it does permit an insightful view of the way in which we run the business that we call dental practice.

The theory has the allure of complex simplicity. The first party is the dentist, the second is the patient and the third is the company, organisation or administrative system that pays the dentist on the patient's behalf. Already we can see the complexity. We can describe both of the first two parties in one word each, dentist, patient. To even begin to define the third party we immediately require a set of descriptive and culturally distinct terms.

Under the two party system of payment the transaction is simple. You the dentist negotiate directly with the patient as to the service you advise, the service they accept and the cost of that service. Each party has one set of communication to deal with. As soon as a third party is introduced, the straight line becomes a triangle and the number of communications required leaps not to three but to six, each party having now to relate to two others. That is, at least two others because the third party has to have systems to check and balance the service being offered and the cost, the service that has been provided and the relative value, as well as provide resources for its own existence.

I am sure you can see what I am driving at and hopefully also understand the thrill I got when I first began to 'see' matters in an apparently clear way. Now it makes not a jot of difference as to whether the third party is a state run system, such as the NHS, a mutual society set up for the benefit of its members, an insurance company, a marketing company, a health company or whatever; the principles remain the same. Before you the dentist can provide a service to the patient, someone else has, at the very least, to be consulted as to whether the service is appropriate, is value for money and can be afforded. Then, if all that is acceptable, the same third party has to have a means of checking that the service has been provided and that it has been carried out according to the agreement. In addition a whole system of possible sanctions, appeals and regulations has to be in place 'just in case'.

There have been many times of uncertainty in dentistry in the UK in the past. That now there is another one is neither particularly surprising, nor entirely unexpected. Additionally, whatever the long drawn out, complex and inevitably bureaucratically heavy outcome of this period of uncertainty will be, another will follow the next time it is perceived that a 'change' is required. It represents the inevitability of a system based on third party payment. It is simple but it is complex.

Practitioners who have opted out of NHS dentistry chose either to change to a different third party system — which they perceived as being more advantageous — or to a two party system, for the same reason. Interestingly, many who swapped their third party are pleased that they did so, but have subsequently moved, or are considering moving, that one step further to a two party system, having been 'shown the way' by virtue of an assisted passage.

I am not suggesting that third party systems are wrong...

I am not suggesting that third party systems are wrong, they have their place in the intricate jumble of a society. What I am attempting to do is to highlight that two is company, three is a crowd and that it will always be so, however benevolent or malevolent or apparently neutral the resulting triangular complexity turns out to be.