The recently revealed safety breach at four Sydney dental clinics has raised questions about the standards of private dental care in Australia. In the following piece, Professors Estie Kruger and Marc Tennant outline the different approaches to regulating safety and quality taken by the public and private dental sectors. They argue that this has resulted in a ‘two tier’ system of dentistry that does not reflect community expectations for health care and propose three possible ways to resolve this issue.
Professors Estie Kruger and Marc Tennant write:
In the last few months in NSW some 11,000 people have received very disturbing letters, outlining the serious risk of disease, originating from a dental practice they attended for routine care.1
Social media comments have highlighted the anger, anxiety and suffering these people endured from this quality failure. Unfortunately this was not an isolated incident, there have been similar occurrences in the past, and this will certainly not be the last.
Dental practice has risk factors that closely align to other interventionist health service providers. For example, dental practices use autoclaves and recycle instruments for use between patients. They therefore need a very strong system of infection control, similar to that required in theatre-based interventions.
Approaches to quality assurance
Over the last 40 years, quality assurance has been a strong and growing area of health policy and practice. This has occurred through a number of different mechanisms. For example, health insurance organisations have generally constructed their policy regimes to ensure care is provided in facilities that have undergone a formal accreditation process.
In the last 5-10 years the Federal government has moved into the area with the development of the National Safety and Quality Health Service Standards (NSQHS Standards) and the National Safety and Quality Accreditation Scheme, overseen by the Australian Commission on Safety and Quality in Health Care (the Commission). The aim of these standards is to support a consistently high level of safety and quality across the spectrum of the health system.
Government-funded dental services in Australia are now participants in the National Safety and Quality Accreditation Scheme, albeit some have been a little slower and less enthusiastic than others. State governments have pushed their participation with the clear acknowledgment that there is risk in dentistry and benefits in implementing mandatory safety and quality standards.
This means that public dental services (where scrutiny is naturally higher) also have independent auditors who undertake site visits to comprehensively assess their practices against the NSQHS Standards.
This contrasts with the situation in private dentistry where the majority of practices are not required to be part of this national system. Unlike public dental services, their participation in the National Safety and Quality Accreditation Scheme and adherence to the NSQHS Standards is voluntary.
This means that scrutiny of safety and quality in private dentistry is minimal, involving a voluntary system of “desk-top” audits, which are regulated by the Australian Dental Association (ADA), the professional body for private dentistry. The ADA explains its role as follows: [quote font_style=”italic”]”… the Commission has appointed the ADA in the role of quasi-regulator of the Dental Practice Accreditation Scheme”.[/quote]2
The result of this approach is that Australia, now has a dichotomous approach to safety and quality in dental care. Clearly, this dichotomy for an interventionist, high risk, discipline sits at odds with the rest of the health sector. It is also evident from the recent quality and safety breach in NSW that this approach needs to be questioned.
Where to from here?
We suspect that most Australians would not believe the current ‘two tier’ approach to safety and quality in dentistry is acceptable.
We understand that there are resource implications for private dentistry in increasing adherence to national safety and quality standards.
Quality systems are about reducing risk and risk reduction requires effort and resources. The costs of an accreditation system to dental practices should be seen as part of the cost of doing business, similar to litigation protection insurance.
We also appreciate that these accreditation costs will hit even those professionals “doing the right thing”. But this is the case in all areas of the health system. Continuous quality improvement is not just about picking up safety and quality breaches, it’s about ensuring our health systems continue to improve by reflecting on their achievements to-date and maintaining currency of practice.
To address the current, unacceptable “two-tier” approach to safety and quality in dentistry three main options are at hand:
- health insurance organisations could start to call for adherence to the NSQHS Standards to be required in order for patients attending private dental practices to receive rebates for care provided. This has for decades been the applicable model in other interventionist domains of the health system, and is directly translatable to dentistry;
- the Commission could take a more robust stance on private dentistry, which reflects its level of risk, and move to strengthen the application of the NSQHS Standards in this area; and
- the profession could reflect on its responsibilities to society and move to eliminate the current dichotomy by bringing all practices into the wider national domain of quality in health.
As dentistry is a profession that cares for Australia society, we hope that the last option, will be the way forward.
- Mills I and Batchelor P (2011). Quality indicators: the rationale behind their use in NHS dentistry. BDJ;211:11-15.
Professors Estie Kruger and Marc Tennant are from the International Research Collaborative – Oral Health and Equity, Department of Anatomy, Physiology and Human Biology, The University of Western Australia.
Conflict of Interest: The authors do not have any known conflicts of interest to declare. MT has been a volunteer surveyor for one of the many accreditation bodies that implement National Standards for nearly a decade; however, this is not considered a conflict of interest.