Describes how dentists see the GDC's decision to allow direct patient access to dental hygienists and therapists.
Illustrates concerns (eg on diagnosis, treatment planning, restorative work, patient safety), and relates such views to dentists' characteristics.
Argues that the direct access reform has highlighted anomalies in the regulatory and educational systems.
Objective To investigate dentists' views on the likely impact of direct access (DA), the clinical competence of hygienists and therapists to work autonomously and possible predictors of such views.
Design Random survey of registered dentists.
Setting UK, 2014.
Subjects and methods A random sample of UK-based dentists registered with the General Dental Council (GDC). A unique-access online questionnaire was developed, with a paper alternative. Email and postal reminders were sent.
Main outcome measures Measures of positive/negative views regarding the impact of DA and clinical competence of hygienists and therapists to work without a dentist's prescription.
Results One hundred and fifty-nine responded (response rate: 27%), 78 (49.1%) of whom were female. No significant sources of response bias were identified. While 122 (77%) had not undergone joint training with dental hygienists or therapists at the undergraduate level, 98 (62.4%) currently worked with a hygienist and 33 (21.0%) with a therapist. Eighty-three (53.2%) disagreed with the GDC decision regarding DA for hygienists, and 94 (59.1%) felt the same regarding therapists. Concern was greatest in respect to diagnosis, treatment planning and restorations. Comments were predominantly negative and reflected concerns over patient safety, what was seen as hygienists' and therapists' inadequate training or expertise, the undermining of the dentist's role, service delivery, the reform being poorly planned, implemented or being a cost-cutting exercise. Experience of teamwork was not predictive of positive/negative views.
Conclusions Response was low, thus posing a potential threat to the study's representativeness. Many dentists had concerns and reservations about DA which were unrelated to teamwork experience. The dissemination of information on curricula and scope of practice may help allay such concerns, as may a greater emphasis on joint training at both the undergraduate level and within continuing professional development programmes.
On 1 May 2013, following a period of consultation and evidence gathering, the General Dental Council (GDC) removed the requirement for patients to be referred by a dentist before being seen by a dental hygienist or therapist. Thus the UK joined a number of other countries in Europe and elsewhere that had developed provision for direct access in one form or another over the last 20 years.1
The British Dental Association was opposed to this change.2 Earlier research by the authors indicated that dentists were concerned about the education, competence and ability of hygienists and therapists to undertake treatments which had been previously viewed as only within the scope of practice of dentists.3 However it was unclear how dentists, and particularly general dental practitioners (GDPs), viewed the reform once it had been implemented and the evidence-base for the decision made public.1,4
Aims and objectives
The aims of this study were to investigate the perceptions of a representative sample of dentists on the likely impact of direct access on dental services, the extent to which different procedures were viewed as being within the clinical competence of hygienists and therapists acting autonomously and possible predictors of such views. The objective was to identify potential problems and barriers to the successful integration of dental hygienists and therapists practicing without referral. The timing of the study, almost one year after the GDC decision, was chosen to identify a more considered view following the controversy which surrounded the decision in 2013.
For brevity the terms 'dental hygienists' and 'dental therapists' are used here, although the dental therapists of today are dually qualified in dental hygiene and dental therapy.
Subjects and methods
The sampling frame was based on the UK GDC register, to which the authors were given access under strict conditions of use and confidentiality. This information included email addresses which were available for 95% of registered dentists. The sample size was calculated on the basis of dentists' likely experience of teamwork, the hypothesis being that such experience may be an important influence on their views on direct access and issues of clinical competence. In early 2014, according to GDC figures, there were approximately 40,300 registered dentists and 8,600 registered dental hygienists and therapists. Previous research by the authors suggested that hygienists and therapists worked between two practices on average.5 Therefore it was estimated that approximately 40% of dentists work with a hygienist or therapist. A random sample of 195 was required to reflect this proportion ± 5% at p = 0.05 and 80% power.
A questionnaire was developed and piloted among a group of 52 research-active GDPs in Scotland (response 41/52; 82%). The main amendments following the pilot study were to clarify questions relating to the impact of direct access where the same response wording could be seen as positive or negative. This was particularly the case in respect to income and costs. Thus the pilot response scale format 'very negative'–'very positive' was changed to 'very harmful'–'very beneficial'.
The final questionnaire covered issues relating to direct patient access to dental hygienists and therapists within the context of their respective scope of practice, including periodontal and preventive treatment, oral health advice, referral for treatment by a dentist and, for therapists, restorative treatment. It also explored the dentist's experience of working and training with these professionals, as well as background questions on the respondents' employment and experience. Most questions used a five-point response scale, ie 'very negative'–'very positive', or 'strongly disagree'–'strongly agree', with space for open-ended comments. The means of values ascribed to items on clinical independent working by hygienists and therapists were computed separately. These summary variables had a range of one to five, with a higher score denoting a more positive view (ie 'strongly agree') of independent working. Responses were analysed using the SPSS software package (v19). Statistical tests employed were Chi-square, unpaired t-tests and ANOVA.
Previous surveys of dentists have reported low response rates. For example, a study of different survey methods achieved response rates between 11% and 26% among US dentists.7 Given the topicality of the subject, a response rate of 30% or more was anticipated. Thus a random sample of 600 was drawn, stratified by UK country of employment and excluding those registered under a non-UK, Channel Islands or Isle of Man address. It was not possible to sample only those working as GDPs or in primary dental care, as this information is not recorded on the GDC register.
In late February 2014 those practitioners for whom the authors had an email address were contacted, introducing the study and providing a hyperlink unique to that individual through which the online questionnaire could be accessed.7 Those without an email address on their GDC record were sent the same information by post. An email reminder to non-respondents was followed by a mailed paper questionnaire sent two weeks after the original communication, and a final reminder/thank you email was sent to all 600 included in the original communication. Data from the GDC register were used to investigate response bias by comparing respondents with non-respondents.
Response and response bias
In total, 159 usable questionnaires were returned, 85 on paper and 74 online. This represented a response rate of 27%. There were no significant differences between respondents and non-respondents by gender, UK country of employment, UK vs non-UK dental school attended, specialist status or years since qualification (Table 1). The only significant interaction found was that responding specialists had more years since qualification than non-responding specialists (t = 2.47, df 44, p = 0.02).
For respondents, these same variables were tested against mode of response. The only significant finding was that specialists (n = 11) were more likely to have responded by post (χ2 = 6.66, df 1, p = 0.01).
Qualitative responses totalled several hundred comments and over 11,000 words. A number of illustrative quotes have been used in this paper, but much rich material had to be omitted for the sake of brevity.
Demographic and professional characteristics
The 159 respondents included 81 males (50.9%) and 78 females (49.7%). The majority (125, 78.6%) worked in England, 21 (13.2%) in Scotland, seven (4.4%) in Northern Ireland and four (2.5%) in Wales. One hundred and twenty (75.5%) worked in general dental practice, including 111 (69.8%) with a mixed private/NHS or predominantly NHS patient list. Thirty-six (22.6%) were practice owners (63.9% males), while 78 (49.1%) were practice associates (69.2% females). Male respondents reported more years since qualification than did female respondents (male mean 21.12 years (SD 12.55); female mean 16.22 years (SD 10.48); t = 2.60, df = 149, p = 0.010).
Experience of teamwork
The majority of respondents (122, 76.7%) stated that their undergraduate dental education had not involved any joint training sessions with dental hygienists or therapists; 16 (10.2%) had trained with hygienists but not therapists, five (3.2%) had trained with therapists but not hygienists, and 13 (8.3%) had trained with both.
With regard to current or past experience of working with a dental hygienist or therapist, experience of working with a hygienist was more common, while few had no experience of working with either (Table 2).
Overall view of direct access
Dentists were asked to indicate their overall view of the GDC decision to allow DA to dental hygienists and therapists, using a five point Likert-type scale ranging from 'very unfavourable' to 'very favourable' (Fig. 1).
For both sets of responses, a majority held unfavourable views. However, dentists' views were significantly more unfavourable regarding DA being made available to dental therapists than to hygienists (z = -2.20, p = 0.02).
A representative selection of positive and negative comments relating to this overall question are given below and grouped by their general theme. For brevity, comments reflecting a neutral or undecided view are omitted, and a maximum of four quotes are given under each heading.
There were 21 positive comments pertaining to patient benefit, nine of which were regarding hygienists:
'Because a minority of [the UK population] attend a dentist [fact in 2012-13 just under half of the adult population had not attended a GDP in the previous 2 years.8] and as a nation our oral hygiene is shocking. It stares you in the face every day, all social classes' [Respondent 47, female salaried dentist, qualified 1980].
'In many cases, this is all the patient needs and it can reduce the time taken by dentists doing scale and polishes and non-surgical periodontal treatment to leave time for other treatment' [Respondent 74, male associate, qualified 2007].
'Well trained, professional person can see patients easily' [Respondent 63, male practice owner, qualified NA].
'A dental practice operating with Hygienists is ideal. It will cover and provide good general dentistry with hygiene and a solid base for referral for specialists if and when necessary and will serve the population very well' [Respondent 76, male senior partner, qualified 1969].
Of the 21 positive comments regarding patient benefit, 12 were regarding therapists, for example:
'Personal experience of how good they are' [Respondent 47, female salaried dentist, qualified 1980].
'Highly qualified professionals' [Respondent 486, male practice owner, qualified 2004].
'Workload reduced for dentist' [Respondent 63, male practice owner, qualified NA].
'Patients can get good basic care at the right time without delay caused during waiting for GDP appointments' [Respondent 50, female salaried dentist, qualified 1996].
There were 23 negative comments pertaining to patient safety, 11 of which were regarding hygienists, for example:
'People will take the easier and cheaper option of visiting the hygienist and believe they have had a dental check-up. Therefore pathology stays undiagnosed.' [Respondent 95, male practice owner, qualified 1981].
'I am worried about patients avoiding dentists for years, in favour of hygienists who are unable to diagnose and manage a range of dental diseases' [Respondent 46, female associate, qualified 2004].
'It could affect patient care with regard to dental issues other than perio for example, oral cancer screening/caries etc' [Respondent 105, male associate, qualified 2004].
'Patients may just attend hygienist rather than attending for routine dental appointments which could result in caries' [Respondent 464, female associate, qualified 2012].
Of the 23 negative comments regarding patient safety, 12 concerned therapists, for example:
'I think patients should have a proper exam with a dentist to determine the treatment plan with X-ray if necessary and/or prescribed medication' [Respondent 29, female associate, qualified 2003].
'I think it will confuse patients and put some at risk of being incorrectly diagnosed and treated' [Respondent 19, female associate, qualified 2007].
'To diagnose and carry out restorative treatment with no regular dentist exam may lead to under/over diagnoses going unchecked. At least yearly dentist check-ups to make sure nothing getting missed.' [Respondent 49, female practice owner, qualified 1989]
'Patients may be under the false impression they do not need to see their dentist if seen by therapists' [Respondent 105, male associate, qualified 2004].
Undermining the dentist's role, poor service planning
There were four comments relating to hygienists:
'I consider this to be a diluting of my profession' [Respondent 34, male practice owner, qualified 1984].
'Patients will be confused by each team member's role' [Respondent 08, male salaried dentist, qualified 2007].
'It's an attempt to meet a need for areas where NHS dental access is poor by providing a service which isn't dentistry. Instead the reasons why dentists left NHS dentistry in these areas should have been addressed.' [Respondent 33, male associate, qualified 2011].
'The huge raft of regulations make it quite difficult to run an operation for a hygienist. Possible problem of incentivised referrals to certain professionals. There are no NHS contracts for Hygienists so it will all be private.' [Respondent 41, male associate, qualified 1980].
There were nine comments relating to therapists:
'The decision making process was pushed through ignoring dentists' [Respondent 64, male corporate dentist, qualified 2004].
'No good evidence to support the decision' [Respondent 87, female specialist, qualified 1987].
'I feel there was nothing wrong with the previous system of patients being seen first by dentist then referred on to the therapist' [Respondent 501, female salaried dentist, qualified 2000].
There were three comments relating to therapists:
'I feel dentists are being pushed out of the NHS as a cost saving exercise' [Respondent 432, female salaried dentist, qualified 2010].
'Because COST motivates this decision. Not patient welfare.' [Respondent 95, male practice owner, qualified 1981].
'They represent the views of government cuts' [Respondent 20, male associate, qualified 2000].
Figure 2 indicates views on the impact of DA on specific aspects of dental services in relation to hygienists, ordered by perceptions of the level of benefit, from the least beneficial to the most beneficial. Figure 3 shows the same information in relation to therapists, with one extra item relating to restorative treatment. The lower Chronbach's alpha score in relation to the items concerning therapists (alpha = 0.618) compared to that relating to items concerning hygienists implies a less consistent view of the likely impact of independent working by therapists, with respondents indicating it would be beneficial in some respects and harmful in others.
Impact on dentists' workload
Views about the potential impact on dentists' workload were equivocal (Fig. 4). The potential benefit was most often viewed in terms of more appropriate specialisation of roles. There was one comment relating to hygienists:
'Allows us to concentrate on more complex cases cutting waiting times for such treatments' [Respondent 300, male practice owner, qualified 1996].
There were 11 comments relating to therapists:
'Dentists able to see more patients for check-ups without time being wasted doing simple restorative treatment' [Respondent 60, female salaried dentist, qualified 2010].
'Dentists will expect therapist to carry out less well remunerated work to free them up for other treatments' [Respondent 86, female practice owner, qualified 1989].
'Transfer of focus onto elements of dentistry that dentists may only perform' [Respondent 67, male corporate dentist, qualified 1993].
Harm was mainly related to a reduction in workload and therefore income.
'I think GDPs will be pushed out the NHS' [Respondent 432, female salaried dentist, qualified 2010].
'The country has trained enough dentists. If management was optimal, access shouldn't need more providers. The dentists who pump out UDA's without a good level of care will no doubt employ more therapists to reduce their costs, lower their level of care.' [Respondent 71, male practice owner, qualified 2005].
'There are already too many dentists treating too few patients, adding more professionals will exacerbate the problem' [Respondent 65, female salaried dentist, qualified 2010].
'They are stealing part of my role and also my income' [Respondent 82, male associate, qualified 1998].
'Patients will deem that attending a hygienist or therapist is cheaper and so the patients will want the hygienist or therapist to do the same job but cheaper' [Respondent 70, male associate, qualified 2003].
'As they would be cheaper to employ, practice principles could tend to favour them to do the bulk of the work in order to profit more personally' [Respondent 73, male associate, qualified 2007].
'More providers the same demand' [Respondent 72, male practice owner, qualified 1981].
'Reduce potential for private work' [Respondent 75, female associate, qualified 1980].
Referrals from hygienists and therapists
Dentists were asked for their reaction to the possibility of receiving referrals from hygienists and therapists for treatments that were beyond their scope of practice (Fig. 5). Here, respondents were generally favourable to such teamwork.
Clinical competence and DA
A series of questions investigated dentists' views on the clinical competence of hygienists and therapists to work without a prescription from a dentist (Fig. 6).
A substantial majority expressed concerns. There was no significant difference between the two sets of responses (z = -1.47, p = 0.14 (ns) excluding 'can't say' responses).
More detail on the nature of such concerns was sought by asking the extent to which dentists agreed or disagreed with hygienists and therapists being permitted to undertake a range of procedures. Figures 7 and 8 illustrate their responses, ordered by level of agreement, which is shown in green.
NHS list/performer numbers
At present NHS list numbers are restricted to dentists. Only 20 (12.7%) agreed that they should be de-restricted while 95 (60.1%) disagreed and 43 (27.2%) were unsure. Comments made by the first group mainly emphasised widening patient access to treatment and greater division of labour, and the cost savings this could bring. Comments by those in the second group covered three main themes: quality of care, dentists' role as the mainstay of dental care, and workforce issues.
Predictors of views on DA
The two variables summarising dentists' views on clinical independent working had a mean of 3.08, sd 0.94, n = 156 for hygienist-performed treatments, and 2.99, sd 0.92, n = 156 for therapists. The two scores correlated at r = 0.66, p = 0.001, n = 156.
The only significant association found was between GDS status and views on DA for therapists (Table 3). The 44 practice owners and senior partners tended to have a more positive view of therapists working without a dentist's prescription than did the 77 associates (mean 3.32 vs mean 2.89, p = 0.037, with Bonferroni correction).
The overall response rate to the survey was poor (27%), but perhaps not atypical. For example, a recent survey of UK GDPs achieved a response rate of 31%.9 Pressure of work, office policy, and frequent requests to complete commercial surveys have been cited as reasons for poor response rates among dentists.10 While methodological reviews suggest features such as brevity or incentives may increase response rates,11 this may not be the case for surveys of dentists.12,13
Low response raises the possibility of response bias and threats to the validity and generalisation of the findings. However, it has been argued that non-response is a source of error only if responders and non-responders differ in crucial ways.14,15 There was no response bias in regard to gender, UK country of employment, UK/non-UK dental school attended, specialist status, or years since qualification. Experience of teamwork was similar to the level indicated by published GDC statistics. However this does not necessarily mean that responders and non-responders were similar in relevant attitudes and beliefs, and that non-responders were 'missing at random'.14 The findings of the study should therefore be interpreted with caution.
As Figures 2 and 3 show, dentists' views on the impact of more independent clinical working varied considerably: for 'traditional' hygienist and therapist activities, positive responses tended to outnumber negative ones, and, taken with the considerable numbers of neutral responses, indicate that most dentists were either favourable or impartial regarding the implications of the DA reform. However this was not true for procedures often seen as within the dentist's sole remit. Referral decisions, risk assessment, diagnosis and treatment planning, and, for therapists, restorations, were felt by a majority to be inappropriate treatments to be undertaken without a dentist's prescription (Fig. 7 and 8).
Attitudes regarding hygienists and therapists performing a range of treatments without a dentist's prescription were difficult to predict. Gender, years since qualification, sector of employment and, perhaps most surprisingly, previous or current experience of working with a hygienist or therapist, were irrelevant in this respect. However, among general dental practitioners associates were significantly more negative towards therapists performing a range of treatments without a dentist's prescription than were practice owners. This may reflect associates' concern over role substitution by therapists. As one practice associate put it: 'it will put associates at risk of unemployment'.
The numerous comments should be seen as indicative of the views and attitudes of some dentists rather than necessarily representative of the majority. Although some positive observations were made, it would appear that there is still much concern and distrust surrounding hygienists and therapists working with greater autonomy. A variety of reasons were put forward, including patient safety, lack of training, and the reform being cost rather than quality driven.
Patient safety was cited by the GDC as the foremost consideration in relation to the DA reform. While two recent reviews1,15 of the research evidence regarding the comparative performance of dentists and DCPs found no evidence that patient safety was at risk, both refer to a shortage of recent good quality comparative studies, and were unable to reach any firm conclusions about the relative effectiveness of dental auxiliaries and dentists. In the present study, references to patient safety most commonly cited the possibility of missed pathology, which depends largely on the level of training received by therapists and hygienists.
The educational process of dental hygienists and hygienist-therapists has changed exponentially in recent years. Most establishments in the UK now offer a three or four year BSc or BSc (Hons) degree in Oral Health Sciences. The learning outcomes contained within the GDC curriculum guidance document Preparing for Practice are almost identical for dentists, hygienists and hygienist-therapists, within their respective scope of practice.16 A number of subject areas are taught jointly with BDS undergraduates, as the level of knowledge required of each group is the same. It could be argued that because of their narrower curriculum, hygienists and therapists spend more time in a clinically supervised environment developing their skills in routine dentistry than do undergraduate dental students. The dissemination of information on curricula and scope of practice may also help allay dentists' concerns, as may a greater emphasis on joint training during programmes of continuing professional development.
Dentists' concerns about hygienists' and therapists standards of operative dentistry may therefore be due to dentists' lack of awareness of their curricula, which suggests that education regarding the quality and extent of training and resulting clinical competence of therapists and hygienists may be required. As one respondent admitted: 'we don't know their level of training'.
Other comments related to the possible financial disadvantages for dentists. There were concerns that there would be a reduced potential for their own private work, and that their role and/or income would be significantly reduced as a result of increased competition. Such concerns are not supported by evidence from abroad, or from medical general practice in the UK, which has seen the emergence of several groups of allied health professionals which work very successfully in their areas of expertise and in tandem with others without detriment to GPs' income (or indeed to patient safety).1,17,18
The 2013 DA reform has served to highlight several areas of regulatory restriction to which hygienists and therapists working in the NHS are still subject. These principally involve prescribing rights in terms of the use of local anaesthesia and fluoride-containing agents, and reporting on radiographic findings. In addition, NHS regulations still permit only dentists to hold a list or performer number which dictates that any hygienist or therapist wishing to set up in independent practice can only do so on a private patient basis.
Perhaps the time has also come to explore other options for the delivery of dental education. While there is much commonality among the BDS and BSc curricula, they continue to remain separate in many ways. We exist in a totally different educational and professional environment, and the BDS programme continues perhaps without sufficient recognition that both the workforce and the oral health needs of the population are changing.
Such prohibitive regulations and inadequately integrated educational programmes now appear outdated. The 2013 DA reform may only be the first step towards the provision of a more flexible, comprehensive and coordinated oral healthcare service which will be required to meet the evolving needs of the public.19,20
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Ross, M., Turner, S. Direct access in the UK: what do dentists really think?. Br Dent J 218, 641–647 (2015). https://doi.org/10.1038/sj.bdj.2015.504
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