The changing skill mix – experiences on the introduction of the dental therapist into general dental practice

Time to complete contemporary dental procedures - estimates from a cross-sectional survey of the dental team

BACKGROUND

There are few contemporary studies on the time taken to complete dental procedures, those most heavily relied on in the United Kingdom date back to 1999.

OBJECTIVES

This work aimed to establish how long members of the dental team took to complete specific dental procedures, relevant to their scope of practice.

METHODS

Data were collected via a purposive sample of 96 dentists, dental hygienists/therapists and dental nurses. Via an online survey, participants were asked to state the mean, minimum and maximum time they estimated that they took to complete individual dental procedures.

RESULTS

The mean time taken to complete procedures common to both dentists and dental hygienists/therapists ranged from 3.7 to 4 min respectively for clinical note reading prior to seeing patients to 30.1 and 28 min to undertake root surface debridement. There were no significant differences between the time taken by dentists and dental hygienists/therapists to treat adult patients. However, in all but one procedure, dental hygienists/therapists reported taking longer (p = 0.04) to treat child patients.

CONCLUSIONS

The data provided here represent an up to date assessment of the time taken to complete specific tasks by different members of the dental team. These data will be of value to service planners and commissioners interested in evolving a dental care system that employs a greater degree of skill-mix and preventively oriented care.

What are the possible barriers and benefits to the use of dental therapists within the UK Military Dental Service?

Introduction All dental service delivery organisations and their workforce need to adopt more efficient and effective delivery models including increased skill-mix.Aim The aim of this study was to investigate the possible barriers/benefits to the utilisation of dental therapists (DTs) in the UK Military Dental Service.Method An explanatory mixed-methods study of sequential design was conducted using purposive sampling of dentists and DTs in the Defence Military Service. Electronic questionnaires (25) were sent to dentists and DTs with an overall response rate of 80% (15/18 dentists and 6/7 DTs). Following analysis of the questionnaires, seven semi-structured interviews (four dentists, three DTs) were thematically analysed.Results All dentists and DTs agreed that DTs could play a positive role within the Defence Military Service, but the barriers and benefits of their use centred on the six main themes of: leadership, delegation, new ways of working, scope of practice, skill-mix and utilisation.Conclusions To address the barriers and maximise the benefits of using DTs, effective leadership at the organisational, dental centre and individual levels is required. This leadership is key to unlocking the benefits of improved teamwork, increased skill-mix and maximised use of all dental care professionals within the Defence Military Service.

The role of dental hygienists and therapists in paediatric oral healthcare in Scotland

Introduction The scope of practice of qualified dental hygienists and therapists allows them to undertake non-surgical periodontal screening, treatment and preventive care, and to diagnose and treatment plan. Therapists are also qualified to restore primary and secondary teeth, and to extract primary teeth. Both professions may see patients directly without needing a dentist's referral. In Scotland, they operate in a context of relatively poor but improving child oral health.Aim To investigate provision of dental care to children, including challenges encountered, by dental hygienists and therapists in the Scottish General Dental Service (GDS).Method An online survey of Scotland-based, GDC-registered dental hygienists and therapists in the GDS.Results Of 426 potential respondents, 194 (46%) responded, including 113 hygienists. Thirty hygienists and six therapists did not currently see child patients. Lack of referrals from dentists/specialisation by other team members, financial/contract reasons and lack of demand were the reasons given. Of those who did see children, most were therapists. Responsibility for preventive paediatric care was evenly split, with 71 (46%) citing the hygienist or therapist and 69 (45%) the dentist. Sixty-five (43%) reported barriers, most commonly relating to parents and children themselves. Time pressures, cost implications for practice and parents, and a number of practice and regulatory barriers were also mentioned.Discussion The response rate is considered to be very good. Limiting factors regarding provision of paediatric dental care include lack of referrals from GDPs and financial or contractual issues.Conclusion There appears to be considerable underuse of hygienists and therapists in respect to paediatric dental care.

Development and retention of the dental workforce: findings from a regional workforce survey and symposium in England

Background

To help promote a flexible and sustainable workforce in dentistry, it is necessary to access accurate and timely data about the structure and nature of the evolving dental team. This paper considers the results and learning from a region-wide dental workforce survey conducted in one area of Health Education England and how the team has changed since the last survey a decade earlier.

Methods

A mixed-methods approach comprised two phases. In Phase 1 a customised workforce questionnaire was sent to all dental practices registered with the Care Quality Commission in the North East of England and North Cumbria in March 2016. Findings then informed Phase 2, a regional symposium held in October 2016, where interactive workshops generated qualitative data that elaborated on factors influencing workforce development.

Results

Of 431 primary dental care practices identified, 228 questionnaires were returned - a 53% response rate. The largest professional groups were dental nurses (n = 1269, 53% by headcount; 50% of fte) and dentists (34% by headcount; 42% by fte), though there had been increases in numbers of all staff groups over the decade, which was most marked for dental therapists (from 1 per 39 dentists to 1 per 8 dentists). The dental team predominantly fell into ‘younger’ age groups (< 46 years age), with evidence of a significant increase in the number of dentists reporting part-time working in a practice since the last survey. Around one third of dental practices reported employing dental nurses with additional skills (n = 74, 32.5%) or dental therapists (n = 73, 32%), and nearly half employed a dental hygienist (n = 104, 46%). However, there was considerable variability in whether these staff actually carried out the range of skills within their scope of practice. Factors shaping workforce development were identified as, the national context, loss of expertise, patients’ health needs and expectations, surgery premises and financial constraints.

Conclusions

The composition and work patterns of the primary care dental workforce have changed markedly over the last decade, though utilisation of skill-mix continues to be constrained. Consideration of factors determining career progression of dentists and dental care professionals is needed to optimise a sustainable future workforce.

Dental therapists in general dental practice. A literature review and case-study analysis to determine what works, why, how and in what circumstances

INTRODUCTION

In the United Kingdom, policy and guidance changes regarding the role of dental therapists (DTs) were implemented in recent years with a view to changing dental care to a more preventive-focussed, teamwork approach. However, success in the adoption of this model of working has been varied.

AIMS

Adopting a realist approach, our aim was, to examine the use of DTs in general dental practices in Wales, exploring what works, why, how and in what circumstances.

MATERIALS AND METHODS

The research comprised two stages. (a) A structured literature search, dual-coding papers for high-level factors describing the conditions or context(s) under which the mechanisms operated to produce outcomes. From this, we derived theories about how skill-mix operates in the general dental service. (b) Six case studies of general dental practices (three with a dental therapist/three without a dental therapist) employing a range of skill-mix models incorporating semi-structured interviews with all team members. We used the case studies/interviews to explore and refine the theories derived from the literature.

RESULTS

Eighty-four papers were coded. From this coding, we identified seven theories which reflected factors influencing general dental practices within three broad contexts: the dental practice as a business, as a healthcare provider and as a workplace. We tested these theories in interviews with 38 dental team members across the six care studies. As a result, we amended five of the theories.

CONCLUSION

Our analysis provides theory about outcomes that DTs may facilitate and the mechanisms that may assist the work of DTs within different contexts of general dental practice.

Feasibility study: assessing the efficacy and social acceptability of using dental hygienist-therapists as front-line clinicians

Background The oral health of the adult population has been improving in the United Kingdom decade upon decade. Over half of dental service activity in the National Health Service (NHS) is limited to a check-up without any further treatment. This raises a question as to whether check-ups could be provided by dental hygienist-therapists, rather than general dental practitioners. The aim of this study was to assess the feasibility of a definitive trial to evaluate the costs and effects of using dental hygienist-therapists to undertake the check-up.Methods/design Adult NHS patients were randomised into three arms in two dental practices: patients who only saw dental hygienist-therapists for a check-up, those that saw the general dental practitioner and dental hygienist-therapist alternatively and a control, where patients only saw the general dental practitioner for their check-up. The study ran for 15 months. The primary outcome measures of the study were patient recruitment, retention and fidelity. A parallel and embedded qualitative study was undertaken which recorded the views of participating patients to determine the social acceptability of the intervention.Results Sixty patients participated in the study. The initial recruitment rate for the study was 33.7%. This figure increased to over 82.1% when telephone calls or face-to-face recruitment was utilised. The retention rates were 60% for both the dental hygienist-therapist only group and the alternate general dental practitioner and dental hygienist-therapist group, compared to 70% for the general dental practitioner only group. Fifteen patients were interviewed in the qualitative study and supported a team approach to the provision of check-ups in the NHS. Conclusion This study demonstrates the feasibility of a definitive trial to evaluate the costs and effects of using dental-hygienist-therapists to undertake the check-up.

Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study

Background

Maximising health gain for a given level and mix of resources is an ethical imperative for health-service planners. Approximately half of all patients who attend a regular NHS dental check-up do not require any further treatment, whereas many in the population do not regularly attend. Thus, the most expensive resource (the dentist) is seeing healthy patients at a time when many of those with disease do not access care. Role substitution in NHS dentistry, where other members of the dental team undertake the clinical tasks previously provided by dentists, has the potential to increase efficiency and the capacity to care and lower costs. However, no studies have empirically investigated the efficiency of NHS dental provision that makes use of role substitution.

Research questions

This programme of research sought to address three research questions: (1) what is the efficiency of NHS dental teams that make use of role substitution?; (2) what are the barriers to, and facilitators of, role substitution in NHS dental practices?; and (3) how do incentives in the remuneration systems influence the organisation of these inputs and production of outputs in the NHS?

Design

Data envelopment analysis was used to develop a productive efficiency frontier for participating NHS practices, which were then compared on a relative basis, after controlling for patient and practice characteristics. External validity was tested using stochastic frontier modelling, while semistructured interviews explored the views of participating dental teams and their patients to role substitution.

Setting

NHS ‘high-street’ general dental practices.

Participants

121 practices across the north of England.

Interventions

No active interventions were undertaken.

Main outcome measures

Relative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients.

Results

The utilisation of non-dentist roles in NHS practices was relatively low, the most common role type being the dental hygienist. Increasing the number of non-dentist team members reduced efficiency. However, it was not possible to determine the relative efficiency of individual team members, as the NHS contracts only with dentists. Financial incentives in the NHS dental contract and the views of practice principals (i.e. senior staff members) were equally important. Bespoke payment and referral systems were required to make role substitution economically viable. Many non-dentist team members were not being used to their full scope of practice and constraints on their ability to prescribe reduced efficiency further. Many non-dentist team members experienced a precarious existence, commonly being employed at multiple practices. Patients had a low level of awareness of the different non-dentist roles in a dental team. Many exhibited an inherent trust in the professional ‘system’, but prior experience of role substitution was important for social acceptability.

Conclusions

Better alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical.

Study limitations

Output data collected did not reflect the quality of care provided by the dental team and the input data were self-reported.

Future work

Further work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Extending dental nurses' duties: a national survey investigating skill-mix in Scotland's child oral health improvement programme (Childsmile)

Background

Childsmile is Scotland’s national child oral health improvement programme. To support the delivery of prevention in general dental practice in keeping with clinical guidelines, Childsmile sought accreditation for extended duty training for dental nurses to deliver clinical preventive care. This approach has allowed extended duty dental nurses (EDDNs) to take on roles traditionally undertaken by general dental practitioners (GDPs). While skill-mix approaches have been found to work well in general medicine, they have not been formally evaluated in dentistry. Understanding the factors which influence nurses’ ability to fully deliver their extended roles is necessary to ensure nurses’ potential is reached and that children receive preventive care in line with clinical guidance in a cost-effective way. This paper investigates the supplementation of GDPs’ roles by EDDNs, in general dental practice across Scotland.

Methods

A cross-sectional postal survey aiming to reach all EDDNs practising in general dental practice in Scotland was undertaken. The survey measured nurses’: role satisfaction, perceived utility of training, frequency, and potential behavioural mediators of, preventive delivery. Frequencies, correlations and multi-variable linear regression were used to analyse the data.

Results

Seventy-three percent of practices responded with 174 eligible nurses returning questionnaires. Respondents reported a very high level of role satisfaction and the majority found their training helpful in preparing them for their extended role. While a high level of preventive delivery was reported, fluoride vanish (FV) was delivered less frequently than dietary advice (DA), or oral hygiene advice (OHA). Delivering FV more frequently was associated with higher role satisfaction (p < 0.001). Those nurses who had been practising longer reported delivering FV less frequently than those more recently qualified (p < 0.001). Perceived difficulty of delivering preventive care (skills) and motivation to do so were most strongly associated with frequency of delivery (p < 0.001 for delivery of FV, DA and OHA).

Conclusions

This study has provided insight into EDDNs’ experiences and demonstrates that with appropriate training and support, EDDNs can supplement GDPs’ roles in general dental practice in Scotland. However, some barriers to delivery were identified with delivery of FV showing scope for improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6831-14-137) contains supplementary material, which is available to authorized users.

Dental skill mix: a cross-sectional analysis of delegation practices between dental and dental hygiene-therapy students involved in team training in the South of England

BACKGROUND

Research suggests that health professionals who have trained together have a better understanding of one another's scope of practice and are thus equipped for teamwork during their professional careers. Dental hygiene-therapists (DHTs) are mid-level providers that can deliver routine care working alongside dentists. This study examines patterns of delegation (selected tasks and patients) by dental students to DHT students training together in an integrated team.

METHODS

A retrospective sample of patient data (n = 2,063) was extracted from a patient management system showing the treatment activities of two student cohorts (dental and DHT) involved in team training in a primary care setting in the South of England over two academic years. The data extracted included key procedures delegated by dental students to DHT students coded by skill-mix of operator (e.g., fissure sealants, restorations, paediatric extractions) and patient demography. χ2 tests were conducted to investigate the relationship between delegation and patient age group, gender, smoking status, payment-exemption status, and social deprivation.

RESULTS

A total of 2,063 patients managed during this period received treatments that could be undertaken by either student type; in total, they received 14,996 treatment procedures. The treatments most commonly delegated were fissure sealants (90%) and restorations (51%); whilst the least delegated were paediatric extractions (2%). Over half of these patients (55%) had at least one instance of delegation from a dental to a DHT student. Associations were found between delegation and patient age group and smoking status (P <0.001). Children under 18 years old had a higher level of delegation (86%) compared with adults of working age (50%) and patients aged 65 years and over (56%). A higher proportion of smokers had been delegated compared with non-smokers (45% cf. 26%; P <0.001).

CONCLUSIONS

The findings suggest that delegation of care to DHT students training as a team with dental students, involved significantly greater experience in treating children and adult smokers, and providing preventive rather than invasive care in this integrated educational and primary care setting. The implications for their contribution to dentistry and the dental team are discussed, along with recommendations for primary care data recording.

Utilization of nondentist providers and attitudes toward new provider models: findings from the National Dental Practice-Based Research Network

OBJECTIVES

The purpose of this study was to quantify, within the National Dental Practice-Based Research Network, current utilization of dental hygienists and assistants with expanded functions and quantify network dentists' attitudes toward a new nondentist provider model - the dental therapist.

METHODS

National Dental Practice-Based Research Network practitioner-investigators participated in a single, cross-sectional administration of a questionnaire.

RESULTS

Current nondentist providers are not being utilized by network practitioner-investigators to the fullest extent allowed by law. Minnesota practitioners, practitioners in large group practices, and those with prior experience with expanded-function nondentist providers delegate at a higher rate and had more-positive perceptions of the new dental therapist model.

CONCLUSIONS

Expanding scopes of practice for dental hygienists and assistants has not translated to the maximal delegation allowed by law among network practices. This finding may provide insight into dentists' acceptance of newer nondentist provider models.

The influence of population oral health on the dental team

This presentation focuses on the use of dental therapists as substitutes for dentists in the provision of some aspects of dental care. Our premise is that the use of therapists is a 'good thing' if it delivers a higher quality service. The care that may be provided by therapists is appropriate to population needs. They have been used to increase access to care in a number of countries by supplementing the volume and reach of services, which enhances equity. Therapists are socially acceptable where they are integrated into existing dental systems, but concerted work may be necessary to increase their acceptability if their use is to be introduced or expanded elsewhere. There is no reason to suspect that therapists offer less effective care than dentists, and available data are compatible with this view. More data may be required to lend political support for their greater use. The efficiency of teams is sensitive to the way in which they are organized and funded. Substitution of dentists by therapists within small dental teams creates complexities and costs that reduce efficiency. Conversely, where therapists can work with relative independence, diagnosing and treating patients without direct supervision, then efficiency may be high. Despite opportunities for improving the quality of care, the main barrier for increasing their use is the dental profession. Dental organizations tend to act as guilds, preventing or restricting the deployment of therapists. Dental public health practitioners therefore have a role as advocates for their greater use. At present, the use of therapists does not appear to be influenced by the health of the population.

Dental practitioner concepts of efficiency related to the use of dental therapists

OBJECTIVES

Efficiency is concerned with producing maximum output with the minimum input, although what constitutes inputs and outputs within an organization is not always clear. Labour substitution is one method of achieving efficiency gains, although cost savings are found to be context dependent and may not be achieved in some situations. Because dental therapists (DTs) in England are permitted to work in dental practices, we set out to investigate how efficiency with respect to the use of DTs is conceptualized by practitioners to deepen our understanding of the potential for substitution to realize efficiency gains in dental practice.

METHODS

Nine dental practices were selected using a purposive sampling methodology to give a range of practice size and DT employment arrangements. Semi-structured interviews were held with 26 dentists. Transcripts were coded and analysed thematically.

RESULTS

Efficiency was perceived as optimum use of surgery time to generate intermediate outputs of (i) managing patient flow to give patient satisfaction and business cash flow and (ii) volume of work (procedures and numbers of patients). DT efficiency gains were evaluated according to whether lower labour costs were offset by a slower working pace and higher rate of failed appointments. Patient need and demand, and whether the practice had health improvement goals, influenced whether DTs were deemed to improve efficiency.

CONCLUSIONS

Findings are in accord with skill mix reviews in wider health care that substitution may be effective in improving efficiency but this may be limited to particular situations where conditions are conducive. More studies are needed to explore these issues further in other dental practice contexts and with other groups of dental auxiliary.

Evaluation of a community-based clinical teaching programme by current and former student dental therapists and dental hygienists: a pilot investigation

AIM

There has been considerable expansion in the involvement of community-based clinical teaching programmes (sometimes termed 'outreach teaching') in UK and other international dental schools. While there has been much interest in the role of this educational methodology in the professional and educational development of student dentists, there has been little, if no, consideration of this form of teaching in relation to dental care professional (DCP) students. The aim of this pilot investigation was to report the feedback and evaluation of current and former student dental therapists and dental hygienists on their experience on the St David's community-based clinical teaching programme at Cardiff.

METHODS

In Autumn 2009, a questionnaire was distributed by hand to the current second year student dental therapist and dental hygiene class at Cardiff (n = 18) and by post to the dental therapist and dental hygiene classes of 2004 (n = 16) and 2007 (n = 17). The questionnaire included both 'open' and 'closed' questions.

RESULTS

Thirty responses were returned (response rate = 59%; 2004 (n = 5, 31%), 2007 (n = 9, 53%), current class (n = 16, 89%)). Seventy percent of respondents (n = 21) reported that they found the community-based clinical teaching programme to be a pleasant working environment and close to subsequent independent practice. Seventy-seven percent (n = 23) reported that their confidence performing nonsurgical periodontal treatment had increased while at the programme. One respondent commented that the programme was '...an invaluable and insightful introduction to what it would be like working in practice. Without being given the experience, it would have been a big shock to the system when I started working in practice...'

CONCLUSION

This pilot investigation has revealed that current and former dental therapist and dental hygiene students are enthusiastic in their support for the inclusion of community-based clinical teaching programmes in their educational and professional development. Most former and current dental therapist and dental hygiene students noted the positive effects of this form of training on their subsequent clinical careers.

Is skill mix profitable in the current NHS dental contract in England?

The use of skill mix in medicine is now widespread, yet it appears that its use in dentistry is not as prominent. Unlike doctors, dentists are required to mitigate the financial risk produced by their capital investment and ensure an adequate cash flow to cover their annual running costs. Examining the financial incentives for employing dental care professionals is therefore an important step to understand why dentistry appears to lag behind medicine in skill mix. It is also apposite, given the announcement of the coalition government to develop a new contract, which could introduce incentives for the use of dental care professionals in this way. The purpose of this short paper is to examine whether skill mix is profitable for general dental practices under the existing NHS contract in England.

An evaluation of a vocational training scheme for dental therapists (TVT)

Commissioned by NHS Education South Central (NESC) Postgraduate Dental Deanery, this work provided an external, independent formative evaluation of the Dental Therapists Vocational Training (TVT) scheme in its first year of operation. Undertaken between March-September 2009, the evaluation engaged with all those involved in the TVT scheme: the newly qualified dental therapists (n = 9; group discussion and questionnaire; portfolio extracts) and interviews with their trainers (n = 9), Associate Postgraduate Dental Dean and TVT Scheme Adviser. Most of those on the scheme did not feel well prepared for work at the point of initial qualification and benefitted from enhancement of confidence and skills. Although the number of treatments undertaken by each of the trainees varied considerably, there was commonality in terms of treatment types. Benefits for trainers included the opportunity to work with a dental therapist and develop a better understanding of their role. They praised the trainees' skills with nervous patients and children and their preventative work. A therapist on the team released the dentist for more complex treatments. Challenges related to the recruitment of trainees and trainers, the relative lack of knowledge about the work of dental therapists, concerns about maintaining the range of therapy skills and issues about UDA (unit of dental activity) distribution. There was widespread support for a mandatory TVT scheme. This scheme could be improved by providing further guidance on the amount and type of clinical experience required.

Benefits and challenges of employing health care assistants in general practice: a qualitative study of GPs' and practice nurses' perspectives

BACKGROUND

Estimates suggest that over half of general practices in England currently employ a health care assistant (HCA) but there is little evidence of their impact, effectiveness and acceptability to patients and primary care team members.

OBJECTIVES

To explore the role of HCAs in general practice and the benefits and challenges associated with their employment.

METHODS

Semi-structured interviews were performed with 6 GPs and 13 practice nurses as part of a larger qualitative study that also included HCAs. Interviewees were from 16 general practices from two Primary Care Trusts in the West Midlands. Transcripts were analyzed using thematic and framework analysis.

RESULTS

HCAs were seen as a valuable addition to the primary care team. They were reported to accelerate, rather than extend services, allow more appropriate use of nurses' skills and enable cost containment. Their training and supervision were felt as time intensive, demanding of time and commitment. Patient safety was raised as a concern, although no specific experience of it being compromised was reported. Nurses recognized the usefulness of HCAs, helped to make the role work, but were often anxious about the impact on their own roles and professional identity. Patients were perceived as being generally neutral or positive.

CONCLUSION

Cost-effectiveness, patient safety, quality of care, potentially contested role boundaries and patient attitudes are among the issues that policy-makers, commissioners and those responsible for workforce development and training need to consider in relation to HCAs in general practice. There is also a need for more in-depth evaluation of this role.

Attitudes of general dental practitioners in Wales towards employing dental hygienist-therapists

AIM

To examine the attitudes of general dental practitioners in Wales with regard to the employment of dually-qualified hygienist-therapists.

DESIGN

Questionnaire.

RESULTS

Responses were received from the principals of 332 of the 550 practices surveyed, a response rate of 60.4%. Fifty-four percent of responding principals currently employed a hygienist and 9% a dually-qualified hygienist-therapist; 43% considered that they were likely to employ hygienist-therapists in the future. Lack of surgery space to accommodate a hygienist-therapist was a problem facing many principals. Disappointingly, respondents demonstrated a clear lack of knowledge in relation to the cost effectiveness of hygienist-therapists, with 39% of principals admitting that this individual would be expected to spend more than half their working time on hygiene treatment. Sixty percent of principals placed an associate among their first three preferences to fill spare capacity, while only 28% selected a hygienist-therapist.

CONCLUSION

This study has provided local evidence to inform workforce planning and identified a need to ensure that all members of the dental team understand the roles and responsibilities of colleagues.