Once a person has made the decision to consult a dentist, there is still the issue of access. Primary dental care – the formal aspect of oral health – is the care provided at the first point of contact. It is necessary to have information about the use of services for planning purposes, both financial and manpower.

Increasingly in recent years, patients are being perceived as consumers who can make choices about what services to use and when they might choose to use them.

Access is made up of five different facets.
These were:

* AVAILABILITY: the relationship between the volume and type of services with the consumers’ volume and type of need. Are there enough providers of care and sufficient facilities for them to work in?

* ACCESSIBILITY: the relationship between the location of the supply of services and the location of the consumer, considering issues such as transportation, distance and cost of travel.

* ACCOMMODATION: the relationship between the organisation of the services, in terms of opening hours and other services, and the patient’s ability to relate to these factors.

* AFFORDABILITY: the relationship of the cost of services to the patients’ ability to pay these costs

* ACCEPTABILITY: the mutual perceptions that both providers and consumers have of each other, in terms of attributes such as age, sex or ethnicity.

These facets can interlink and have a synergistic effect. The major policy focus has tended to be on the facet of availability. However, as availability decreases, it becomes harder for the consumers to access services. There is a range of evidence identifying the factors are important in explaining the use of services, which have been summarized as epidemiological, demographic, socioeconomic, personal and psychological, and the characteristics of the system.

The issue of equitable access has also been highlighted. There is a concept known as ‘inverse care law’. This proposes that the provision of health care is inversely related to the need for it. This was demonstrated in a study of access to dental services. which investigated the uptake of treatment by 508 14-year old children in different social classes in two towns in England with different dentist: population ratios. In the town with an unfavorable dentist: population ratio, the uptake of treatment was considerably higher in the social classes. In the town with a favorable dentist: population ratio, the uptake was similar throughout the social scale. This suggests that patients from lower social classes are put at a further disadvantage when there are fewer dentists available.
There are a number of barriers to accessing professional care, including fear and anxiety, the cost of treatment and aspects of dental practice environment. The impact of these different barriers has been evaluated by researchers. Three thousand five hundred adults were invited to consider 15 statements: five on aspects of fear, five on the cost of treatment and five on the aspects of dental practice organization. A minority of the sample (11%) indicated that they perceived no barriers to dental care, 45% selected a barrier related to fear, and equal numbers (22%) selected barriers related either to practice organization or to cost. Women were more likely to identify with statements, especially those related to fear, while those respondents who attended only with dental problems were more likely to associate themselves with all statements, with fear being most important.
Although self-reports of barriers are informative, some validation of such findings is also needed. While respondents may perceive barriers, it does not necessarily mean that this will have an impact upon their oral health. However, the oral cavity is particularly accessible to examination compared with other parts of the body, and a strength of the study was that they included a clinical examination of respondents.
There were, indeed, correlations between reported barriers due to fear and dental condition. Fearful patients were more likely to have more missing teeth and fewer filled teeth than those not reporting any barrier statements. That these two factors are correlated together does not necessarily propose a casual practical implication of this finding would appear to be that these patients were delaying accessing treatment until it was difficult for the dentist to provide an adequate restoration.

 
Dr. BERTRAND R. STUART DDS.