Clarity, not ambiguity!

Clarity, not ambiguity!

As we approach the 4th anniversary of our gaining the right to see patients without referral from a dentist - the huge controversy that was 'direct access’ - it is important to consider whether or not anything has really changed for most of us.

This directive was heralded as an opportunity for us to prove our worth as 'independent professionals' deserving and earning that status, on an equal footing with our dentist colleagues. Has this happened? I suspect not. Many, if not most, of us still work under the direct, and not always accurate, prescription of a dentist. Of course there is nothing wrong with working in teams, indeed some of us argued for that to be enshrined in the changes that took place at the GDC in May 2013, but what if the prescription is inappropriate?

I have discussed in these editorials before the issue of 'cosmetic' scale and polishes carried out privately on NHS patients. As long as patients, I still struggle with the term 'customers', understand that this is a cosmetic procedure rather than therapeutic one then I'm sure we all would have no problem with that: treating the patient as a whole rather than focussing on their pathology is part of being a caring professional. If they feel better after a scale and polish then there is nothing unprofessional about such provision, any more than there is anything unprofessional about tooth whitening.

The area where I begin to feel uncomfortable is when NHS patients are charged privately for treatment of extant disease. Practices, groups of practices, principals and 'corporates' use all kinds of semantics to justify charging separately for hygienist services: 'calculus is not a disease'; 'the NHS only covers basic care'; 'hygienist visits constitute cosmetic treatment and this is not available on the NHS’…

My question for colleagues who work in mixed practice where patients are routinely charged privately for hygienist time is whether they share the burden of misleading patients, if that is what is happening.

Both the NHS guidelines, as published on the NHS website1 and GDC guidance2 would suggest that if a scale and polish is required on an NHS patient it should be provided under band 1 and that the patient should not be induced to pay privately, this is even more clear cut for the treatment of periodontal disease under band 2. Where we as professionals seem to have difficulty is in defining what is 'required' to maintain oral health (i.e. 'what is clinically necessary’). However, surely this is carefully laid out in the guidance from BSP on the BPE3? A BPE code 2 in any sextant requires treatment, in many cases this will probably be the removal of supra-gingival calculus, a plaque-retentive factor. In essence then, it would appear to be difficult to maintain an argument that hygienist services should be charged for privately in mixed practice unless the treatment is limited to the cosmetic removal of stain and the patient displays clear consent to treatment that is unnecessary for their health.

I genuinely believe that most patients do not understand the subtlety that underpins the difference between the NHS and private care and would see hygienist visits as beneficial for health, but surely it is our duty as independent professionals to:

1. Understand that subtlety ourselves; and

2. Make sure that our patients understand it too, in terms that they can understand and consent to.

I am aware that this might create difficulties for some colleagues in some workplaces but the independence that we won four years ago surely means that we share the responsibility for keeping patients fully informed?


1. NHS Choices. The NHS will provide any clinically necessary treatment needed to keep your mouth, teeth and gums healthy and free of pain. 

2. GDC Standards. 1.7.2 If you work in a practice that provides both NHS (or equivalent health service) and private treatment (a mixed practice), you must make clear to your patients which treatments can be provided under the NHS (or equivalent health service) and which can only be provided on a private basis. 

1.7.3 You must not mislead patients into believing that treatments which are available on the NHS (or equivalent health service) can only be provided privately. If you work in a purely private practice, you should make sure that patients know this before they attend for treatment. 

1.7.4 If you work in a mixed practice, you must not pressurise patients into having private treatment if it is available to them under the NHS (or equivalent health service) and they would prefer to have it under the NHS (or equivalent health service). 

3. The BSP’s Good Practitioner’s Guide’ can be downloaded in pdf or completed in e-learning format by visiting


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