Failure on all fronts: general dental practitioners' views on promoting oral health in high caries risk children--a qualitative study.

BACKGROUND: Despite overall improvements in oral health, a large number of children in United Kingdom (UK) are affected by dental caries; and the implementation of oral health promotion in some families remains a challenge. As such, children from those families suffer high caries rates, and are frequently referred for tooth extraction under General Anaesthesia (GA), one of the commonest reasons for paediatric hospital admissions. The aim of this investigation is to explore referring primary care General Dental Practitioners' (GDPs) views and experiences in trying to promote better oral health for those children. METHOD: A qualitative study, utilizing face-to-face, semi-structured interviews with GDPs in three London boroughs who refer children for extraction of decayed teeth under GA selected based on referral rate. Qualitative Framework Analysis was used to present the results. RESULTS: Eighteen GDPs (56% male) were interviewed: average age 42 years (range: 26-73 years). informants reported challenges to promotion of oral health categorised as: (1) child's young age, poor cooperation, and high treatment need; (2) parental skills to face up to modern day challenges and poor attitudes towards good oral health (3); social inequality, exclusion and cultural barriers in immigrant families; (4) National Health Services (NHS) primary care practice remuneration, constraints and training; (5) inadequate secondary care communication and engagement; and (6) failure in establishing national policy to grasp the width and depth of the problem. CONCLUSION: GDPs feel frustrated and isolated in their efforts to promote oral health in those children. These findings suggest difficult challenges on all fronts. Reform of preventive dentistry funding and delivery, as well as a multiagency multidimensional approach that is mindful of the social determinants of children's oral health and barriers to application of oral and wider health initiatives are needed to address this important public health issue.

Clinical directors' views of centralisation and commissioning of cleft services in the U.K.

BACKGROUND: To determine the views of Clinical Directors working in the United Kingdom (U.K.) Cleft Service with regard to centralisation, commissioning and impact on cleft service provision. METHODS: In-depth qualitative interviews were conducted with 11 Clinical Directors representing regional cleft services. Interviews were transcribed verbatim, a coding frame was developed by two researchers and transcripts were coded using a thematic, 'interpretive' approach. RESULTS: Clinical Directors perceived the commissioning of cleft services in the U.K. to be dependent upon historical agreements and individual negotiation despite service centralisation. Furthermore, Clinical Directors perceived unfairness in the commissioning and funding of cleft services and reported inconsistencies in funding models and service costs that have implications for delivering an equitable cleft service with an effective Multidisciplinary Team. CONCLUSIONS: National Health Service (NHS) commissioning bodies can learn lessons from the centralisation of cleft care. Clinical Directors' accounts of their relationships with specialist commissioning bodies and their perspectives of funding cleft services may serve to increase parity and improve the commissioning of cleft services in the U.K.

Guidance for commissioning NHS England dental conscious sedation services: a framework tool.

Conscious sedation is an integral part of modern day dental care and should be delivered through a high quality, effective and evidence-based approach. Commissioning of NHS dental services in England is currently under review by NHS England and the National Dental Commissioning Group. This group has identified the management of vulnerable people including anxious patients, as one of its priorities. The Society for the Advancement of Anaesthesia in Dentistry (SAAD) believes this provides an opportunity to influence the commissioning of NHS conscious sedation services. With this aim in mind,"Guidance for Commissioning NHS England Dental Conscious Sedation Services: A Framework Tool" was developed. This guidance proposes a common approach to the organisation of NHS dental conscious sedation services in England, advocating the provision of Tier 1 and Tier 2 services in all regions. Its ethos is a"hub and spoke" model of service delivery with patient assessment delivered by experienced and well trained dental sedationists at its core. In line with the recent Francis Report fundamental standards for all aspects of dental conscious sedation practice are outlined, supported by a robust and predictable quality assurance process. This work has been shared with key stakeholders in NHS England including the Chief Dental Officer and the Head of Primary Care Commissioning.

NHS pilots in primary care--an insight into the future?

UNLABELLED: This article looks at the background to the current changes in primary care dentistry being piloted in England. It looks at the structure of the different elements being piloted, such as the oral health assessment, interim care appointments and care pathways. It also examines advanced care pathways and how complex care will be provided when clinically feasible and beneficial to the patient. The authors have worked in a type 1 pilot practice since September 2010. CLINICAL RELEVANCE: The NHS contract currently being piloted in England delivers care through care pathways and clinical risk assessments with prevention as an important building block for the delivery of services. There are new measures planned for measuring quality outcomes in primary care. This has implications for how services are delivered, who delivers them and how dentists will be remunerated in the future.

Determining the optimal model for role-substitution in NHS dental services in the United Kingdom.

BACKGROUND: Role-substitution describes a model of dental care where Dental Care Professionals (DCPs) provide some of the clinical activity previously undertaken by General Dental Practitioners. This has the potential to increase technical efficiency, the capacity to care and reduce costs. Technical efficiency is defined as the production of the maximum amount of output from a given amount of input so that the service operates at the production frontier i.e. optimal level of productivity. Academic research into technical efficiency is becoming increasingly utilised in health care, although no studies have investigated the efficiency of NHS dentistry or role-substitution in high-street dental practices. The aim of this study is to examine the barriers and enablers that exist for role-substitution in general dental practices in the NHS and to determine the most technically efficient model for role-substitution. METHODS/DESIGN: A screening questionnaire will be sent to DCPs to determine the type and location of role-substitutive models employed in NHS dental practices in the United Kingdom (UK). Semi-structured interviews will then be conducted with practice owners, DCPs and patients at selected sites identified by the questionnaire. Detail will be recorded about the organisational structure of the dental team, the number of NHS hours worked and the clinical activity undertaken. The interviews will continue until saturation and will record the views and attitudes of the members of the dental team. Final numbers of interviews will be determined by saturation.The second work-stream will examine the technical efficiency of the selected practices using Data Envelopment Analysis and Stochastic Frontier Modeling. The former is a non-parametric technique and is considered to be a highly flexible approach for applied health applications. The latter is parametric and is based on frontier regression models that estimate a conventional cost function. DISCUSSION: Maximising health for a given level and mix of resources is an ethical imperative for health service planners. This study will determine the technical efficiency of role-substitution and so address one of the key recommendations of the Independent Review of NHS dentistry in England.

Letter from America: UK and US state-funded dental provision.

OBJECTIVES: Current UK and US economic conditions have re-focussed attention on the need to deliver dental care with limited finance and resources. This raises hard questions determining which services will be offered and what they should achieve to satisfy public demands and needs. We consider impending dental health reforms in the US and UK within the context of contemporary experiences to identify issues and delivery goals for the two nations. BACKGROUND: The paper provides a brief history and background of the development of social dental care models in the UK and US, highlighting some differences in state-funded delivery of dental care. SHIFTING DEMAND: From the 1950s, demand for dental treatment has increased and acquired a more complex composition growing from predominantly surgical and restorative treatment to encompass preventive care and cosmetic services. PRIORITISING CARE ACCORDING TO NEED: Despite improvements in general health and technology, inequalities in access and utilisation of dental care are still experienced, primarily by groups with low socio-economic status. DELIVERY: BALANCING RESOURCES, DEMAND AND NEED: In developing and delivering reform agendas, much can be learned from previous policy interventions. Pressures of cost, coverage, and capacity, besides demand versus need must be carefully considered and balanced to deliver quality service and value for users and taxpayers. CONCLUSIONS: Ethical and moral consideration should be given to making services needs-driven to address high treatment requirements rather than the high care demands of the worried well. This challenge brings the additional political pressure of convincing many of the voters (and subsequent complainers) that their demands may be less important than the needs of others.

A description of a specialist led primary care based oral surgery service.

AIM: To describe the establishment of a referral only oral surgery service in a primary care setting together with the challenges, benefits and successes of the service. PROBLEM: In 1994 waiting times for hospital for oral surgery and maxillofacial procedures were unacceptably long. A proposal to establish a primary care oral surgery service aimed to complement the hospital-based service, reduce treatment delays. OUTCOME: Referrals commenced immediately in response to a managed launch with local dentists recognising the service as a source of expedient and convenient treatment for their patients. The service now treats up to 1300 patients per year. LEARNING POINTS: New dental services to dentistry can encompass different specialities. Initial capital investment is needed to develop a more cost-effective service. Recruitment of suitable specialist staff is a critical for success. Staffing, organisation and funding must be sustained.

The effect of overbooking on idle dental chair capacity in the Pretoria region of the Gauteng Oral Health Services.

An analysis of annual reports revealed that on average 20% of patient appointments with oral hygienists in the Department of Health in the Pretoria region were not utilised due to patient noncompliance (i.e. broken appointments). Many solutions have been considered to address the high rate of noncompliance and the resulting idle chair capacity. One solution selected to overcome some of the negative consequences of broken appointments was deliberate overbooking. The aim of our study was to determine the effect of overbooking on idle dental chair capacity by measuring the utilisation rate over a three month period (July to September) after 25% overbooking was introduced in the Pretoria region. A statistical analysis was conducted on our results to determine an overbooking rate that would ensure full utilisation of the available dental chair capacity. The available time units over the three month study period amounted to 1365, allocated to 1427 patients resulting in an overal overbooking rate of 4.54%. The overall utilisation rate was found to be 79.2%. The calculated regression line estimated that there would be full utilisation of dental chair capacity at an overbooking rate of 26.7%. Overbooking at the levels applied in this study had a minimal overall effect on idle dental chair capacity. Our results confirm the need for careful planning and management in addressing noncompliance. In a manner similar to the clinical situation, organisational development requires a correct diagnosis in order that an appropriate and effective intervention may be designed.

The impact of changes in incentives and governance on the motivation of dental practitioners.

Recent changes to the system of remuneration and contracting arrangements with Primary Care Trusts (PCTs) has meant that dental practitioners in the UK have experienced several types of incentive and governance arrangements. This paper uses data from a qualitative study of 20 dental practitioners to examine the influence of different systems of incentives and governance on their motivational system. Results show that a perceived reduction in autonomy was the least acceptable aspect of the health reforms. The study also suggests that conflict between self-interested and altruistic motives may occur where medical professionals operate as independent contractors in a small business environment. Whilst dentists appeared to show altruistic motives towards their patients, priorities towards running an autonomous business enterprise meant that PCT managerial requirements, for example, to widen access were not welcomed, because of their impact on managerial autonomy. Moreover, whilst dentists' professional ethos appeared geared towards achieving technically high quality standards of work, this produced tensions against a background of cost containment in a fee-per-item system of remuneration. The paper raises issues such as the person-system interaction associated with professional and individual autonomy and the importance of reciprocity and fair payment.

Proposed career pathway for clinical academic general dental practitioners.

The Modernising Medical Careers framework provides the opportunity for both medical specialists and general medical practitioners to follow training pathways that lead to appointments as National Health Service (NHS) consultants and to senior academic posts. Similar opportunities are available for dentists who wish to specialise. However, they are not available to dentists working in primary dental care who wish to become NHS consultants or senior academics in general dentistry. An alternative pathway is required that does not force committed primary care dentists who wish to become NHS consultants or senior academics down a path of specialisation. In this paper, the authors explore the situation in some detail and propose a career pathway with appropriate competencies for primary care dentists who aspire to become NHS consultants or senior academics. They justify why such posts should be created. The competencies have been developed using key guidelines and documents from the European Bologna Process and the Association for Dental Education in Europe, the Curriculum for UK Dental Foundation Programme Training, and the General Dental Council monospecialty curricula. It is hoped that the proposed pathway will produce highly trained generalists who will: (a) encourage and undertake research in primary dental care, where over 90% of dentistry is delivered, (b) support and lead outreach centres so that teaching and clinical cases reflect primary dental care, where students will spend their working lives post-qualification, and (c) provide a means of increasing the numbers of clinical dental academics, which have been in decline over the last 10 years.

A review of effective methods of delivery of care: skill-mix and service transfer to primary care settings.

AIMS: Health policy in England is seeking to minimise hospital use and provide access to services in a primary healthcare setting and maximise skill-mix, driven by issues such as cost and access. The aim of this review was to determine the effectiveness of increased use of skill-mix and service transfer within general and oral healthcare. Secondary outcome measures were related to cost, quality, access, health outcomes and satisfaction. METHODS: Data sources were the Cochrane Database of Systematic Reviews, Centre for Reviews and Dissemination DARE, British Nursing Index, CINAHL, EMBASE, MEDLINE, and PsycINFO from 1996 to August 2008. The reference lists of relevant papers were scanned to identify additional studies. DATA SELECTION: A rapid appraisal of systematic reviews, randomised controlled trials, controlled trials and service evaluations in relation to specialist services, practitioners with a special interest, medical and dental, nursing and dental care professionals, together with evidence of service shifts from secondary to primary care was undertaken. RESULTS: A total of 206 papers were reviewed. All titles and abstracts of articles and papers found were extracted and validated according to predefined criteria. They were screened for relevance by two researchers, who assessed trial quality and extracted data. Twenty-six papers met the inclusion criteria. The literature demonstrated limited evidence of the cost-effectiveness and health outcomes associated with changes in setting and skill-mix. However, there was evidence of improved access, patient and professional satisfaction. CONCLUSIONS: There is an overwhelming need for well-designed interventions with robust evaluation to examine cost-effectiveness and benefits to patients and the health workforce.

Improving access to dental care for older people.

UNLABELLED: Population demography is changing and the proportion of older people in society is increasing globally, particularly in western countries. Furthermore, as many more people survive into older age and retain their natural teeth so their risk of oral disease remains, or increases, bringing challenges such as root caries and periodontal diseases, together with the long-term effects of dental care. Despite their increased need, the uptake of dental care by older people is characteristically poor and unmet need may be high. Barriers to the uptake of care include a lack of perceived need, together with concerns about availability, cost and fear. This paper therefore outlines a series of actions for dental teams to take to minimize barriers and facilitate the uptake of dental care amongst older people. It draws on the findings of research conducted amongst older adults living in the community in a socially deprived inner city area as well as the wider literature. CLINICAL RELEVANCE: It is important for dental teams to reflect on the difficulties that older people face while trying to access dental care services and, where possible, to address them in order to facilitate dental attendance amongst this section of the population who have much to gain from high quality preventively orientated care.

Improving access to oral surgery services in primary care.

This paper describes the innovative use of National Health Service (NHS) dental commissioning powers to develop specialist primary care based oral surgery services. The outcomes, after one full year of the scheme, have been substantial improvement in access and reduced waiting times for patients, further development of NHS primary care dental services through commissioning processes, increased use and engagement of oral surgery specialists outside of a hospital setting, and considerable ongoing savings to the NHS. Collaborative working between hospital consultants and managers, Primary Care Trust dental commissioners, general dental practice providers, specialist oral surgeons and a dental public health consultant has resulted in sustainable benefits to patients and the NHS within the World Class Commissioning framework.

A question of value: a qualitative study of vocational dental practitioners' views on oral healthcare systems and their future careers.

BACKGROUND: New dental graduates in England and Wales spend one year as vocational dental practitioners (VDPs) preparing for independent clinical practice. In recent years, they have entered a state-funded healthcare system undergoing the greatest period of change since the inception of the National Health Service (NHS) and a profession in which there has been a significant shift of care to the private sector. Against this background, the objectives of this study were to investigate VDPs' vision of their future professional career and the influences that will impact on their choice of state-funded (NHS) and/or private dentistry, and to identify what factors may attract graduates to work for the NHS. METHODS: In 2004/2005, purposive sampling of a range of VDP training schemes across England and Wales was used to select the VDPs from ten schemes to take part in focus groups. To standardise data collection, a topic guide was used. Respondents' views were recorded on tape and field notes. The data were transcribed and analysed using framework methodology. RESULTS: Ninety-nine VDPs from all parts of England and Wales participated in ten focus groups. They identified three main categories of future practice: private, state-funded (NHS), and mixed. Private practice was perceived as providing 'professional independence', 'financial reward', 'time with patients' and 'clinical freedom'. NHS practice was associated with 'providing access to specialist training' and 'gaining clinical experience', often as preparation for private practice. Providing NHS care was attractive for VDPs who valued the ethos of public service. The VDPs considered that NHS practice could be made more attractive to young dentists by a range of factors, involving the funding, culture and philosophy of the system and the degree of fit with their personal and professional vision. They reported that they would welcome 'incentives to work in areas of high need', 'assistance with debt' and a 'culture of valuing NHS dentists'. CONCLUSIONS: The findings suggest that the commitment to healthcare systems of the VDPs who took part in this study was associated with being true to their values and being valued within the system. They perceived a tension between state-funded and private practice, considering the latter more likely to meet personal and professional expectations. However, they remained open to working in an enhanced and supportive state-funded system, should it correspond with their values, and demonstrate that they were valued healthcare professionals.

An investigation of the attitudes and fears of vocational dental practitioners in England and wales in 2007.

AIM: The aim of this study was to investigate whether recent changes in the National Health Service (NHS) dental contract may have caused increased anxiety and concern among vocational dental practitioners (VDPs). METHOD: A total of 606 questionnaires, which had previously been piloted, were distributed to VDPs across England and Wales at the end of the vocational training (VT) year in 2007. The questionnaires contained a range of questions about VDPs' attitudes and fears, the influence that they perceived the new dental contract for the General Dental Services of the NHS had on their VT training experience, and their expectations for the future. RESULTS: A 71% response rate was achieved. The results reflected changes in opinion about the dental profession among VDPs between when they applied for university and six years later on their completion of VT. During this period, they reported that their feelings of job security had declined from 93.1% (n=390) to 34.1% (n=145) and financial security from 94.8% (n=405) to 51.5% (n=219). Anxiety about the potential lack of funding in the NHS was felt by 77.6% (n=330). The effect of increasing numbers of dental graduates on employment prospects produced anxiety in 72.5% (n=305) of VDPs. On completion of VT, 19.4% (n=83) of VDPs did not have employment for the following year. CONCLUSION: At present, the future is more uncertain for new dental graduates than in the past. The dental profession needs to become more aware of the pressures that graduates are facing and further research is needed to investigate them and the effects that they are having on the future of dentistry.