If you work in dental regulation or compliance in England, you’ll know that the number one question doing the rounds right now is:
Do dental teams need Tier 1 or Tier 2 Oliver McGowan training?
And with mixed messages coming from training providers, professional networks, and even CQC inspectors, it’s no wonder practices are confused.
So here is a clear, plain‑English breakdown of what the law says, what the Code of Practice expects, what CQC are saying — and ultimately, how a dental practice can make a confident, defensible decision.
- What the law actually requires
Amendments to the Health and Social Care Act 2008 introduced a legal duty for all staff working in a regulated activity (including dentistry) to receive autism and learning disability training that is:
“appropriate to the person’s role”
However, nothing in the Act specifies Tiers. That’s an important point.
- So…what’s the role of the Oliver McGowan Code of Practice?
The Code of Practice is the government-issued document in line with Section 21A of the above Act designed to explain how providers should meet the legal duty. It introduces the Tier structure and gives examples of which roles map to which Tier.
Whilst the Code itself is only recognised as “the preferred and recommended training package to support registered providers to meet the legal requirement”, it is important to note that:
- CQC must take account of the Code of Practice when assessing compliance
- If a provider chooses not to follow it, the burden of proof is on the provider to justify why
- CQC can take enforcement action if the training is not appropriate to the role
That means the Code shouldn’t be treated as optional guidance – it’s the reference point CQC uses to judge compliance with the law.
- What does the Code say about Tier 1 vs Tier 2 in primary care?
The Code of Practice gives the following definitions:
Tier 1 – “All staff who require a general awareness of the support that autistic people or people with a learning disability may need”
Tier 2 – “Health and social care staff with responsibility for providing direct treatment, care or support, and other professionals working in health and care settings with a high degree of autonomy”
Although the Code does not specifically address dental practices, it includes guidance for primary care, which dentistry falls under. This states that:
- Tier 1 is likely required for staff who are not involved in direct patient contact or decision-making
- Tier 2 is likely required for those who provide clinical services
However, the guidance for primary care also suggests that reception teams are “likely to need Tier 2 capabilities” because they may need to recognise when reasonable adjustments are required.
This creates a degree of inconsistency within the Code, particularly when applied to the dental context, because reception staff in dental practices:
- Do not typically provide direct treatment, care or support, and
- Do not typically hold a high degree of autonomy
…which are the criteria underpinning the formal Tier 2 definition.
Therefore, when applying the Code proportionately within the context of general dental practice, it would be reasonable to interpret training needs as follows:
- Tier 1 – Reception teams and administrative roles
- Tier 2 – Dentists, dental care professionals, and registered managers
This reflects both the requirements of the law (“appropriate to the person’s role”) and the practical realities of how dental practices operate, while still demonstrating alignment with the Code of Practice.
- Why this matters for dental practices
Dental practices have high public footfall and routinely encounter autistic people and people with learning disabilities, whether those patients disclose it or not.
The Oliver McGown employer guidance reinforces this:
“Tier 2 is for health and social care staff with responsibility for providing care and support for an autistic person or a person with a learning disability. This is anyone who provides, or who may be required to provide, a service to a person with a learning disability or an autistic person, regardless of how often that may occur.”
So, when you combine:
- Patient-facing roles
- Responsibility for clinical care
- The requirement to recognise reasonable adjustments
…the argument for Tier 2 becomes strong for most clinical staff.
- So why the conflicting messages from CQC?
This is where practices are understandably frustrated.
Evidence from recent CQC visits suggests that inspectors are not strongly pushing for Tier 2 training, with some reportedly saying:
“It’s a practice choice…as long as you’ve done some training, that’s fine”
This variation in messaging adds to the confusion. It may be that inspectors are taking a pragmatic, proportionate approach, focusing on whether training is relevant and role-appropriate rather than formally checking whether Tier 2 has been completed. Alternatively, the issue may simply be an inconsistent interpretation with inspectors interpreting and applying the Code differently.
However, without the CQC providing a clear, definitive stance, what we are seeing in practice does not fully align with the Code of Practice or the CQC’s own guidance, which states that they:
- Must consider the Code when assessing providers
- Will use it to judge whether training is appropriate to the role
- May use it to support enforcement action if providers do not meet the requirement
What is clear is that Tier 2 remains the interpretation for dental teams that is most closely aligned with the current Code, even if it is not being strictly enforced across dental inspections.
- So, what should a dental practice do?
Here’s a clear, pragmatic way to look at it:
If your staff are involved in direct patient care or participate in decision-making that affects patients:
- Tier 2 is the safer, more defensible, Code-aligned option
If a staff member is not involved in direct patient care:
- Tier 1 is likely appropriate
If you choose not to follow the Tier 2 expectations, be prepared to:
- Document your rationale
- Show how training remains “appropriate to the role”
- Show how you meet the legal duty equally effectively, and
- Demonstrate how patients with learning disabilities/autism are protected from inappropriate care
That’s not impossible, but it does require a clear, evidence-based explanation.
- The bottom line
Many of us in the dental sector recognise that Tier 1 feels far more proportionate to the level of contact, complexity, and duration of interactions typical in general dental practices. Tier 2 training, in its current form, is challenging for practices, as a full one-day, face-to-face session is:
- Disruptive to service delivery
- Costly
- Logistically difficult
- Arguably designed with hospitals, community services, and care settings in mind
This is why many practices, based on risk, practicality, and proportionality, feel Tier 1 is more appropriate, even though the current Code leans toward Tier 2 for clinical roles.
However…
Until the guidance or Code of Practice is formally updated, the framework continues to link roles involved in direct patient care to Tier 2 capabilities. Even though CQC are not currently enforcing this strictly in dental settings, the Code remains the reference document that inspectors must take into account when assessing whether training is “appropriate to the role”.
Because of this, practices should be prepared to either:
- Deliver Tier 2 training for clinical team members, or
- Clearly document and justify why Tier 1 is proportionate and appropriate within their setting
This isn’t about ticking a box.
It’s about ensuring the dental sector can confidently deliver care that is welcoming, safe, and inclusive for autistic people and people with learning disabilities. And whilst there is no explicit legal requirement stating, “Tier 2 must be done”, it remains the stronger, more defensible position for most clinical team members under the current framework.
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