The English NHS provides essential treatments for teeth, periodontal tissues and the mouth, including free oral and dental treatment for people under 19, pregnant people and 12 months after birth, patients whose treatment is carried out by a hospital dentist after being treated in an NHS hospital, those receiving low-income benefits and dependants under 20 years old.1

To develop effective and equitable delivery of dental care services, since 2006, the dentists having NHS contracts have been paid to provide an agreed level of dental activity each year, measured in units of dental activity (UDAs) from April until the following March, paid in 12-monthly instalments. The NHS recovers the unused funds if the dentist does not fulfil 96% or more of the agreed UDAs. However, if these units run out, patients have to go elsewhere or wait until the NHS practice receives its new quota. Since 2011, there have been many pilots within the dental contract reform programme to improve the contracts and commissioning with dentists to improve access to oral and dental care. This programme ended on 31 March 2022 and all prototype contracts returned to follow the contractual terms and conditions of general dental service or personal dental services.2

Accessibility to healthcare is defined as the opportunity to reach and/or obtain the healthcare services that fulfil the seekers' needs.3,4,5,6 Evaluating access to healthcare is a complex process3,7,8,9 but most researchers have agreed that the ultimate access to healthcare is a collective outcome that stems from the interface between five accessibility dimensions of healthcare service provision: i) approachability; ii) acceptability; iii) availability and accommodation; iv) affordability; and v) appropriateness.2 These dimensions are influenced by the individuals' abilities to obtain needed services (ie to perceive; to seek; to reach; to pay; to engage), as well as determinants related to the characteristics of individuals, the community and health system and/or service providers. These determinants are the principal barriers and/or facilitators for accessing healthcare.3,4,5,10

Harris (2013)8 proposed that measurement of patient access could be realised by assessing two metrics incorporating four measurable constructs:

Entry access - defined as ‘whether individuals and groups can receive initial care', determined and influenced by measuring two constructs: i) service availability and ii) realised initial and continued access

Effective access - defined as ‘the proportion of the population in need of an intervention that receives an effective intervention', determined by: iii) equity and iv outcome of care constructs.

Several UK-based studies identified different factors that influence access to NHS oral and dental care services (Table 1). Some factors are related to the healthcare system (eg structural barriers)11,12,13,14 whereas others are associated with patients' circumstances and population characteristics (eg personal barriers).13,15,16,17,18

Entry access to NHS primary dental care services for patients is a perennial issue in the UK.6,8,19,20,21 Even prior to the COVID-19 pandemic, O´Connor et al.22 declared shortfalls in entry access to NHS dental care for children and adults, as 58.4% of children and 49.6% of adults were seen by an NHS dentist in 2019.23 Subsequently, the British Dental Association estimated that over 38 million dental appointments were missed over the course of the pandemic alone.2 Despite efforts by the NHS to promote oral and dental care quality and access, the problem of NHS dental care access continues to worsen and has exacerbated since the advent of the COVID-19 pandemic.2 In the UK, the lack of NHS dental care access or delayed dental treatment has led to increased patient pain, destruction of tooth tissue, and in severe cases, infections and worsening dental and periodontal status, with subsequent potentially avoidable tooth loss.24

Despite some improvement in entry access to NHS oral and dental care shown by the GP Patient Survey in 2022/2023, the UK House of Commons stressed that the success rate in securing NHS dental care appointments is still below a 92% success rate compared to 2019.255

Shortcomings in the equity and quality of the NHS dental care services (effective access) have been attributed to multiple factors, as summarised in Table 1, and vary between impacts of the current NHS system, professional regulations and policymakers' views on the provision of person-focused, prevention-based and sustainable care,26,27 whilst also impacting on dentists' productivity and wellbeing.28 Further factors are patients' low perception and awareness of NHS oral and dental care provision13 and inequities in NHS oral and dental care provision for different age, ethnic, sex and social groups.18,29,30 More recently, a semi-structured interview of 20 dentists in England found that they faced multiple factors that negatively influenced their physical, psychological and emotional health and consequently, their dental care quality provision.22 These factors were related to professional regulations, health systems, job specifications, relationships and personal life.31

Few studies have investigated the enablers and facilitators of better effective oral and dental care access in the NHS. One study considered using NHS Direct to promote equitable 24-hour and out-of-hours access to NHS dental care.32 Another study looked at initiating direct access by the General Dental Council in 2013 to allow dental hygienists and dental therapists to treat patients independently without treatment prescriptions from a dentist first.28,29 A third study considered how the NHS welfare system effectively reduced the negative impact of social differences in oral health improvement and reduced inequalities in dental care access in the UK.33,34 The Fuller Stocktake report34 also considered the potential positive role of the NHS 111 (out-of-hours on-call) and direct access integration into primary and urgent care routine access. Yet, in 2017, concerns were raised by General Dental Council-registered dental hygienists and dental therapists offering direct access centred around the lack of dental nurse support and the limited availability of periodontal treatment under NHS regulations.35 Consequently, NHS England produced guidance for the use of skill mix within NHS general dental practice36 and clarified dental therapists' and dental hygienists' roles within the oral healthcare team in providing patient care within NHS primary dental services (eg diagnostic and treatment work) through direct access.