Modelling a Consultant Workforce for the United Kingdom: needs-based planning for Dental Public Health.

OBJECTIVE: To develop a needs-based workforce planning model to explore specialist workforce capacity and capability for the effective, efficient, and safe provision of services in the United Kingdom (UK); and test the model using Dental Public Health (DPH). BASIC RESEARCH DESIGN: Data from a national workforce survey, national audit, and specialty workshops in 2020 and 2021 set the parameters for a safe effective DPH workforce. A working group drawing on external expertise, developed a conceptual workforce model which informed the mathematical modelling, taking a Markovian approach. The latter enabled the consideration of possible scenarios relating to workforce development. It involved exploration of capacity within each career stage in DPH across a time horizon of 15 years. Workforce capacity requirements were calculated, informed by past principles. RESULTS: Currently an estimated 100 whole time equivalent (WTE) specialists are required to provide a realistic basic capacity nationally for DPH across the UK given the range of organisations, population growth, complexity and diversity of specialty roles. In February 2022 the specialty had 53.55 WTE academic/service consultants, thus a significant gap. The modelling evidence suggests a reduction in DPH specialist capacity towards a steady state in line with the current rate of training, recruitment and retention. The scenario involving increasing training numbers and drawing on other sources of public health trained dentists whilst retaining expertise within DPH has the potential to build workforce capacity. CONCLUSIONS: Current capacity is below basic requirements and approaching 'steady state'. Retention and innovative capacity building are required to secure and safeguard the provision of specialist DPH services to meet the needs of the UK health and care systems.

Moving from advocacy to activism? The fourth WHO global forum on human resources for health and implications for dentistry.

As we debate shaping the future oral health workforce within the UK, to meet the needs of current and future populations, it is helpful to take an international perspective on this very important issue. Globally, there is a strong recognition that human resources for health (HRH) are fundamentally important to deliver effective care, accessible to all people. This paper reviews the outcome of the fourth global forum held by the World Health Organisation (WHO) in Dublin which highlighted the urgency for action. The main objectives of the forum were to advance the implementation of (i) the WHO Global Strategy on HRH 2030 and (ii) the United Nations High-Level Commission's Health Employment and Economic Growth recommendations. From an oral health perspective, the global burden of oral disease remains huge with untreated dental caries, periodontal disease and tooth loss ranking among the most prevalent conditions worldwide. Major considerations are how dental education, practice delivery and/or oral health systems as a whole could and should innovate to accommodate the growing needs of the population. As dental professionals, it also becomes necessary for us to engage and play a proactive role in this change process. Due to growing differences between population needs and available services, it is necessary for oral health personnel to work more closely with the broader health workforce so as to identify solutions that are in the best interests of the patients and populations at large.

Ethnic Disparities in Oral Health Related Quality of Life among Adults in London, England.

OBJECTIVE: To explore ethnic disparities in oral health related quality of life (OHQoL) among adults, and the role that socioeconomic factors play in that association. RESEARCH DESIGN: Data from 705 adults from a socially deprived, ethnically diverse metropolitan area of London (England) were analysed for this study. Ethnicity was self-assigned based on the 2001 UK Census categories. OHQoL was measured using the Oral Health Impact Profile (OHIP-14), which provides information on the prevalence, extent and intensity of oral impacts on quality of life in the previous 12 months. Ethnic disparities were assessed in logistic regression models for prevalence of oral impacts and negative binomial regression models for extent and intensity of oral impacts. RESULTS: The prevalence of oral impacts was 12.7% (95% CI: 10.2-15.1) and the mean OHIP-14 extent and severity scores were 0.27 (95% CI: 0.20-0.34) and 4.19 (95% CI: 3.74-4.64), respectively. Black adults showed greater and Asian adults lower prevalence, extent and severity of oral impacts than White adults. However, significant differences were only found for the extent of oral impacts; Black adults reporting more and Asian adults fewer OHIP-14 items affected than their White counterparts. After adjustments for socioeconomic factors, Asian adults had significantly fewer OHIP-14 items affected than White adults (rate ratio: 0.28; 95%CI: 0.08-0.94). CONCLUSION: This study found disparities in OHQoL between the three main ethnic groups in South East London. Asian adults had better and Black adults had similar OHQoL than White adults after accounting for demographic and social factors.

Do high tuition fees make a difference? Characteristics of applicants to UK medical and dental schools before and after the introduction of high tuition fees in 2012.

Aim To compare trends in the volume, socio-demography and academic experience of UK applicants and entrants to medicine and dentistry in the UK with university in general, before and after the major increase in university fees in England in 2012.Methods Descriptive trend analyses of University and College Admissions Services (UCAS) data for focused (preferred subject was medicine or dentistry) and accepted applicants, 2010-14, compared with university in general in relation to socio-demography (age, sex, ethnicity, POLAR 2, region) and academic experience (school type). POLAR2 data provide an indication of the likelihood of young people in the area participating in further or higher education.Results In 2012 the volume of applicants to medicine and dentistry fell by 2.4% and 7.8% respectively, compared with 6.6% for university overall. Medical applications remained buoyant and by 2014 had risen by 10.2% from 2010 to 23,365. While dental applications fell in both 2012 and 2013, they had increased by 15.6% to 3,410 in 2014, above 2010 levels. Females formed the majority of applicants, and admissions, with the proportion gaining admission to dentistry in 2014 reaching an all-time high (64%), exceeding medicine (56%), and university in general (56%). Mature admissions to dentistry were at their highest in 2010 (29%) falling to 21% in 2014, compared with 22-24% in medicine. Black and minority ethnic group admissions to university, although rising (24% in 2014), are still less than for medicine (34%) and dentistry (48%). In 2013, just over half of the students admitted to dentistry were from BME groups (51%) for dentistry. Among UK applicants <19 years, over 60% of applicants, and 70% of accepted applicants, to medicine and dentistry are from the top two POLAR2 quintiles representing areas of high participation in education; however, in 2014 there was a notable increase in the proportion of applications from the lower two quintiles to dentistry (19%) and medicine (20%), with a very modest increase in those gaining admission over 2012 (14% of both; cf 10% and 12% respectively).Discussion The findings suggest that the short-term impact of the 2012 rise in fees had a greater influence on the volume and nature of applicants to dentistry than medicine, and that both programmes are gaining in popularity, despite high fees and reduced places. Dentistry remains particularly attractive to Asians, and females, the latter forming an increasing majority of students. While there is some recovery, social inequalities exist and present a challenge for widening participation in the professions.

Listening to older adults: community consultation on a new dental service.

BACKGROUND: Increased life expectancy, retention of a natural dentition often heavily restored, and increasing risks of oral disease mean that older people have particular dental needs and yet uptake of care is low. A new health and wellbeing centre in south London offering student-delivered care has been built to serve the local community. Community views could informed the planning of acceptable care for older people. OBJECTIVE: To explore the views and expectations of older adults towards dental services and ascertain how a new dental centre may best provide dental care. RESEARCH DESIGN: This qualitative study used in-depth and triad interviews to explore the views of older people. Purposive sampling of local centres/groups for older adults was undertaken and all willing clients interviewed. Interviews were audio recorded, transcribed and analysed using Framework Methodology with emerging themes categorised according to Maxwell's six descriptors of quality. RESULTS: Nine sessions (five triad and four in-depth interviews) involving 17 older adults were conducted in local day centres. Barriers to dental care were largely related to fear, cost, transport, lack of perceived need and the attitude of clinicians. Outcomes related to acceptability featured highly in a dental service for older adults; the overarching principles of 'delivering mutual benefit' for students and older people, 'experiencing warm humanity' and 'restoring dignity and worth' were central to their views of quality care. The importance of clinicians, whether student or staff, delivering person centred care with warm humanity was dominant: comprising 'welcoming', 'valuing', 'listening' 'communicating' and 'caring' for older adults to enhance relationships and contributing to 'restoring dignity and worth'. CONCLUSION: Community engagement identified a willingness amongst older adults to utilise dental services where mutual benefit was perceived and, importantly, there were low barriers to care and a warm humanity was exhibited.

Dentists with extended skills: the challenge of innovation.

BACKGROUND: The aim was to obtain stakeholders' views on the former London Deanery's joint educational service development initiative to train dentists with a special interest (DwSIs) in endodontics in conjunction with the National Health Services (NHS) and examine the models of care provided. METHODS: A convergent parallel mixed methods design including audit of four different models of care, semi-structured interviews of a range of key stakeholders (including the DwSI trainees) and questionnaire surveys of patients and primary care dentists. RESULTS: Eight dentists treated over 1,600 endodontic cases of moderate complexity over a two year training period. A retrospective audit of four schemes suggested that first molars were the most commonly treated tooth (57%; n = 341). Patients who received care in the latter stages of the initiative were 'satisfied' or 'very satisfied' with the service (89%; n = 98). Most dental practitioners agreed that having access to such services would support the care of their patients (89%; n = 215) with 88%; (n = 214) supporting the view that DwSIs should accept referrals from outside of their practice. CONCLUSION: This initiative, developed to provide endodontic care of medium complexity in a primary care setting, received wide support from stakeholders including patients and primary care dentists. The implications for care pathways, commissioning and further research are discussed.

Care home managers' views of dental services for older people living in nursing and residential homes in inner city London.

OBJECTIVE: To investigate care home managers' views on the provision of dental care (current and future; urgent, check-up and follow-up) for their residents, barriers to care and the impact of policy changes, by type of home (nursing vs residential), with a view to informing the planning and provision of care. BASIC RESEARCH DESIGN: A cross sectional postal questionnaire survey and follow-up semi-structured interviews. SETTING: Care homes in South East London. PARTCIPANTS: All care home managers in three south east London boroughs. RESULTS: A 72% response rate (n=152) was achieved, 140 of which were designated as nursing and/or residential homes (92%). Almost all managers reported that the care homes had arrangements in place for residents to access some elements of dental care (99%, n=148). Reported barriers to care included residents' fear of treatment (53%), patients' limited mobility (45%) and waiting times for services (42%). Limited mobility (p=0.01) and transport issues (p=0.01) were more significant barriers for nursing homes, whereas fear (p=0.02) was more significant for residential homes. Access to a range of dental services and modes of service delivery were requested for the future; most notable were the demands for domiciliary services to be available to nursing homes and for residential homes to access local general dental practitioners to meet the needs of their residents. CONCLUSIONS: Managers report having arrangements in place for residents to access dental services; however, there was a clear view that future arrangements should be more appropriate to the needs and vulnerabilities of their residents.

Developing professional status: an investigation into the working patterns, working relationships and vision for the future of UK clinical dental technicians.

AIMS: To investigate the working patterns and patient base of registered clinical dental technicians (CDTs); their relationships with dentists and other professionals in the dental team; their willingness to work within the NHS and their expectations for the future as a new professional group. METHODS: Face-to-face qualitative interviews of registered CDTs, selected because of their geographic representation and mode of working, informed the development of a postal questionnaire survey of all early registrants with the General Dental Council (GDC). RESULTS: The majority of CDTs reported working part-time, often combining clinical practice with their role as a dental technician. They reported both positive and negative working relationships with dentists and dental technicians, demonstrating collaboration and/or competition depending on whether the scope of CDTs was respected and patient care was shared or lost. CDTs role in the NHS was limited because they did not have the status of becoming a recognised provider of dental care. There was a desire to expand their scope of practice in future. CONCLUSION: CDTs are embracing their new status as an occupational group within dentistry. Core features of becoming a professional group were exhibited including the importance of social and financial status and the need to negotiate their current and future roles in the healthcare system.

Revolutionising the dental curriculum--delivering better oral health.

There is a paradigm shift taking place in healthcare with the recognition that every consultation should count for health - not merely the treatment of disease - drawing on the principles of health promotion and underpinned by a strong evidence-base for clinical prevention. Institutions such as King's Health Partners [KHP], an academic health science centre in London, recognise that its responsibilities extend beyond the clinical environment to the local community and beyond and that there should be greater emphasis on promoting health. This paper outlines recent proposals by Dental Institute as a clinical academic group within KHP to promote health, the underlying philosophy, actions taken and the evidence-based resources available, as well as the challenges to be overcome.

Modelling workforce skill-mix: how can dental professionals meet the needs and demands of older people in England?

BACKGROUND: There is an urgent need to consider the skill-mix of the dental team to meet the oral health needs and demands of the population in general, and older people in particular. As people live longer and retain their teeth there will be a progressive change in both the volume and type of dental care required, and the demand for care. Operational research modelling provides the opportunity to examine and test future scenarios for National Health Service (NHS) care. AIM: The aim of this research was to explore the required skill-mix of the dental team to meet future need and demand of older people in England to 2028 utilising operational research methods and to examine a range of future scenarios. METHOD: A three-stage computer model was developed to consider demand for dental care, workforce supply and skill-mix. First, the demand model combined population demography and a marker of oral health with attendance and treatment rates based on NHS activity data. Monte Carlo simulation was used to give an indication of the uncertainty surrounding this projected demand. Second, projections on workforce supply and other assumptions relating to clinical hours, NHS commitment and workforce whole time equivalents (WTEs) were analysed to produce a range of estimates for the current and future workforce. Third, staff skill-mix competencies were examined and the data fed into an optimisation model. Linear programming was used to give the optimal workforce makeup and predictions for workforce requirements. Five future scenarios were run from 'no skill-mix' through to 'maximum skill-mix' in the dental team, and the outputs compared. RESULTS: The results indicate that by 2028 there will be an increase in demand for care among older people of over 80% to almost 8.8 million hours; however, Monte Carlo simulation suggests considerable uncertainty surrounding the demand model outputs with demand deviating from the average in terms of treatment hours by as much as 22%. Modelling a healthcare system with 'no skill-mix' resulted in the lowest volume of clinical staff equivalents (dentists: 8,668) providing care for older people, whereas maximum skill-mix involved more staff (clinical staff = 10,337, of whom 2,623 were dentists, 4,180 hygienist/therapists and 3,534 clinical dental technicians) if all care is provided at the relevant level of competence. CONCLUSION: The model suggests that with widening skill-mix, dental care professionals can play a major role in building dental care capacity for older people in future. The implications for health policy, professional bodies and dental teamworking are discussed.

Informing the debate on oral health care for older people: a qualitative study of older people's views on oral health and oral health care.

BACKGROUND: Older people represent a growing and diverse section of the population. As age increases, people are more likely to experience health and mobility problems and be at higher risk of developing oral disease. Nevertheless, few older people utilise primary oral healthcare services. It is therefore important to understand the value older people place on oral health and dental services to inform providers and planners of oral health care. This research was conducted as part of a study to identify potential ways of minimising barriers to oral health care in older people. OBJECTIVES: To explore perceptions of oral health and oral healthcare services amongst older people living in a socially deprived inner city area and how these are related to service utilisation. METHODS: A qualitative approach was utilised to explore the range of issues related to older people's perceptions of oral health and their views on health care. This involved a combination of focus groups and semi-structured individual interviews with older people and their carers. Data analysis was conducted using the Framework approach. RESULTS: * RESPONSE: Thirty-nine older people and/or their carers participated in focus groups. * Oral health perception: Oral health was associated with the presence of natural teeth, the absence of pain, practical/social functioning, preferably supported by positive assessment by a dentist. * Oral health life-course: Older people have a long and complex dental history. Past negative experiences with oral health care, especially in childhood, strongly influenced present attitudes towards dentistry and dental personnel. * Citizenship and right to health care: There was a strong perception that, as 'British citizens', older people should have a right to free health care and that the National Health Service (NHS) should support them in this phase of their life. CONCLUSIONS: The oral health life-course of older people is an important influence on their perceptions of oral health and dental attendance. They consider oral health of importance and place great emphasis on their citizenship and rights of access to state funded oral health care. This raises important issues for the funding and delivery of NHS oral health care for older people.

Widening access? Characteristics of applicants to medical and dental schools, compared with UCAS.

AIM: The aim of this paper is to compare the demography (age, sex, ethnicity, social status) and academic experience (school type, tariff scores) of focused and successful applicants to preclinical dentistry with preclinical medicine, and with higher education in general in the UK. METHOD: Retrospective analyses of anonymised University and College Admissions Services (UCAS) data for focused applicants whose preferred subject was preclinical dentistry or medicine, and accepted (successful) applicants to the same programmes in 2006. These data were compared with publicly available data on applicants and accepted applicants through UCAS. Information for each medical, dental and general UCAS applicant included age, sex, ethnicity, socio-economic group, region, school type and tariff score. Logistic regression was used to model the probability of being accepted in relation to all explanatory variables and interactions. RESULTS: In total there were 2,577 focused applicants to dentistry; 1,114 applicants were accepted, 4% (n = 46) of whom did not have it as their preferred subject choice. There were seven times as many focused applicants for medicine (18,943) when compared with dentistry; 8,011 applicants were accepted, 2.7% of whom did not have medicine as their preferred subject choice (n = 218). Just over half of the applicants to dentistry were from minority ethnic backgrounds (50.5%), exceeding medicine (29.5%), and higher education in general (19%). The proportion of female applicants was similar across all three groups at around 55%. Only one fifth (21%) of focused applicants to dentistry were mature compared with one third (33%) to medicine and one quarter (25.5%) of all UCAS applicants. Greater proportions of applicants to medicine (25.8%) and dentistry (23.5%) were from upper socio-economic backgrounds, compared with higher education in general (15.5%). When all other factors are controlled, the odds of being accepted for medicine, and for dentistry, are lower if mature, male, from a lower social class, from a minority ethnic group and have attended a further/higher education college. CONCLUSIONS: Focused and successful applicants for preclinical medicine and dentistry are more likely to be from higher social classes and a minority ethnic background than applicants to higher education in general. Dentistry attracts twice the level of Asian applicants as medicine and four times that of universities in general. Controlling for other factors, there is evidence that gender, ethnicity, maturity, and school type are associated with probability of acceptance for medicine and dentistry. Higher social status is particularly associated with acceptance for medicine. The implications of these findings are discussed in terms of widening access and social justice.

Deprivation and access to dental care in a socially diverse metropolitan area.

BACKGROUND: Primary Care Trusts (PCTs) in England have a responsibility to ensure that the oral health needs of their residents are addressed. This will involve monitoring the uptake of primary dental care and developing services to address local needs and demands. OBJECTIVE: To examine the relationship between dental registration, age, gender and deprivation at ward and borough level within a socially diverse metropolitan area. METHODS: This retrospective, cross-sectional ecological study was conducted using ward level registration data for residents of south east London from the Dental Practice Board, population data from the Office of National Statistics and the Index of Multiple Deprivation (IMD) from the Office of the Deputy Prime Minister. Registration rates were calculated at ward level for the population as a whole and for specific age bands. The correlation with deprivation was examined using Pearson's correlation co-efficient and the data mapped. RESULTS: Registration varied by gender (40% females registered compared with 35% males) and age (children aged 6-12 years (62%) were most likely to be registered and 0-2-year-olds least likely (11%). There was a strong negative correlation between deprivation (IMD) and registration in the 0-5 year (r = -0.82; p < 001) and 6-17 year (r = -0.81; p < 0.001) age-bands across the sector and similarly within each borough. The negative correlation was most marked in the most affluent borough (r = -0.87; p < 0.001). CONCLUSION: Analysis of registration for dental care across a socially diverse area reveals a strong negative correlation between NHS service uptake and deprivation status amongst children only. Inequalities in service utilisation by children were most marked within affluent boroughs, compared with deprived boroughs.

The future dental workforce?

The Editor-in-Chief of the BDJ has previously raised important questions about dental workforce planning and the implications for dental graduates of recent changes and pressures. It is now time to revisit this issue. Much has changed since the last workforce review in England and Wales, and the rate of change is in all probability set to increase. First, at the time of writing this paper the momentous step of including dental care professionals (DCPs) on General Dental Council (GDC) registers in the United Kingdom has recently been completed. Second, the Scope of Practice of all dental professionals has been under consultation by the General Dental Council, and research evidence suggests that greater use should be made of skill-mix in the dental team. Third, within England, Lord Darzi has just published the 'Final Report of the NHS Next Stage Review', which emphasises 'quality care' and 'team-working' as key features of healthcare; this report was accompanied by an important document entitled 'A High Quality Workforce', in which plans for local workforce planning within the NHS are outlined, placing responsibilities at national, local and regional levels. Fourth, policy makers across the UK are wrestling with addressing oral health needs, promoting health and facilitating access to dental care, all of which have implications for the nature and shape of the dental workforce. Fifth, with the impact of globalisation and European policies we are net gainers of dentists as well as having more in training. Sixth, although there have been reviews and policy initiatives by regulatory, professional and other bodies in support of shaping the dental workforce, there has been little serious consideration of skill-mix and funding mechanisms to encourage team-working. Together, these events demand that we enter a fresh debate on the future dental workforce which should extend beyond professional and national boundaries and inform workforce planning. This debate is of great importance to future generations of dental healthcare professionals, funders, commissioners and providers of both dental services and dental education and training, and most importantly our patients and the public whom we serve. Furthermore, workforce planning must be linked to a philosophy of care which promotes promotion of health and embraces quality care, rather than merely treatment of disease, and addresses oral health needs and demands.

Special Care Dentistry: a professional challenge.

As a profession we have a responsibility to ensure that the oral health needs of individuals and groups who have a physical, sensory, intellectual, medical, emotional or social impairment or disability are met. In the UK, over 200,000 adults have profound learning disabilities and/or complex medical conditions. Adults with a disability often have poorer oral health, poorer health outcomes and poorer access to services than the rest of the population. This paper examines the need for Special Care Dentistry based on a review of published literature, surveys and health policy, and suggests how services might be delivered in the future. Existing models of good practice reveal that established clinicians working in this field have a patient base of between 850 and 1,500 patients per year and work across primary care and hospital settings, liaising with colleagues in health, social services and the voluntary sector to ensure integrated health care planning. On this basis, a conservative estimate of 133 specialists is suggested for the future, working in networks with Dentists with Special Interests (DwSIs) and primary dental care practitioners. A skilled workforce that can address the wider needs of people requiring Special Care Dentistry should be formally recognised and developed within the UK to ensure that the needs of the most vulnerable sections of the community are addressed in future.

Oral health status and dental service use of adults with learning disabilities living in residential institutions and in the community.

OBJECTIVE: To investigate the oral health status of adults on Sheffield's Learning Disability Case Register, and their reported use of dental services. DESIGN: A short questionnaire interview of subjects with learning disabilities or their carers followed by a standardised epidemiological examination, by one trained and calibrated examiner. SETTING: Residential homes, day centres or community homes of people with learning disabilities in Sheffield. SUBJECTS: A 20% random sample of adults (18-65 years) on the register. RESULTS: A response rate of 209 (67%) was achieved, 62% (n=130) of whom were living in the community. People living in residential care were significantly older (43.2 years) than those based in the community (36.3 years) (P<0.05). Both groups had similar mean DMFT scores; however, adults living in the community had significantly more untreated decay (DT = 1.6) and poorer oral hygiene than their counterparts in residential care (DT = 0.7). Adults in residential care had significantly more missing teeth (MT = 10.1) than those in community care (MT = 7.5). General and community dental services were the main providers of dental care. Subjects living in the community were significantly less likely to have a dentist and to use community dental services than their residential counterparts; they were more likely to attend only when having trouble. CONCLUSIONS: Adults with learning disabilities living in the community have greater unmet oral health needs than their residential counterparts and are less likely to have regular contact with dental services. Commissioners and providers of dental services have a responsibility to ensure that the health of adults with learning disabilities is not compromised by 'normalisation'.

Toxicological evaluation of complex industrial wastes: implications for exposure assessment.

We evaluated a variety of short-term bioassays to construct a battery of tests that could be used for assessing the biological effects of potentially hazardous complex industrial wastes. Ten samples were studied for hepatotoxicity; these samples and an additional 5 were studied for mutagenicity. Although the data are limited to these samples, the results suggest that the Salmonella assay (strain TA98) or a prophage-induction assay (both in the presence of S9) in combination with determination of relative liver weight and levels of a set of serum enzymes in rats may provide a battery of tests suitable to characterize complex industrial wastes for mutagenic and hepatotoxic potential. The biological activities exhibited by the wastes were not readily predicted by the chemical profiles of the wastes, emphasizing the importance of characterizing potentially hazardous complex industrial wastes by both chemical and biological means. DNA from liver, lung and bladder of rats exposed to some of the wastes was analyzed by the 32P-postlabeling technique for the presence of DNA adducts. A waste that produced mutagenic urine produced a DNA adduct in bladder DNA. The implications of this approach for assessment of exposure to complex hazardous waste mixtures are discussed.