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

uSing rolE-substitutioN In care homes to improve ORal health (SENIOR): a study protocol

Background

Dental service provision in the care home sector is poor, with little emphasis on prevention. Emerging evidence suggests that the use of Dental Care Professionals (dental therapists and dental nurses) as an alternative to dentists has the potential to improve preventive advice, the provision of care and access to services within care homes. However, robust empirical evidence from definitive trials on how to successfully implement and sustain these interventions within care homes is currently lacking. The aim of the study is to determine whether Dental Care Professionals could reduce plaque levels of dentate older adults (65 + years) residing in care homes.

Methods

This protocol describes a two-arm cluster-randomised controlled trial that will be undertaken in care homes across Wales, Northern Ireland and England. In the intervention arm, the dental therapists will visit the care homes every 6 months to assess and then treat eligible residents, where necessary. All treatment will be conducted within their Scope of Practice. Dental nurses will visit the care homes every month for the first 3 months and then three-monthly afterwards to promulgate advice to improve the day-to-day prevention offered to residents by carers. The control arm will be ‘treatment as usual’.

Eligible care homes (n = 40) will be randomised based on a 1:1 ratio (20 intervention and 20 control), with an average of seven residents recruited in each home resulting in an estimated sample of 280. Assessments will be undertaken at baseline, 6 months and 12 months and will include a dental examination and quality of life questionnaires. Care home staff will collect weekly information on the residents’ oral health (e.g. episodes of pain and unscheduled care). The primary outcome will be a binary classification of the mean reduction in Silness-Löe Plaque Index at 6 months. A parallel process evaluation will be undertaken to explore the intervention’s acceptability and how it could be embedded in standard practice (described in a separate paper), whilst a cost-effectiveness analysis will examine the potential long-term costs and benefits of the intervention.

Discussion

This trial will provide evidence on how to successfully implement and sustain a Dental Care Professional-led intervention within care homes to promote access and prevention.

Trial registration

ISRCTN16332897. Registered on 3 December 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06487-3.

Satisfaction with dental care services in Great Britain 1998-2019

Background

Satisfaction with dental services can provide valuable insights into aspects of quality including access as well as changes in this over time. In the UK publicly funded dental services are ostensibly delivered by private sector general dental practitioners for whom private patients represent an opportunity cost to the provision of care to public patients. This study examined changes in satisfaction as economic circumstances and policy changed in Britain between 1998 and 2019.

Methods

Data were taken from successive waves of the British Social Attitudes Survey a representative cross-sectional survey of the population between 1998 and 2019. Descriptive statistics and a series of logistic regression analyses were used to examine the relationships between satisfaction and a range of socio-demographic characteristics over time.

Results

37,328 usable responses were extracted from the survey spanning 21 years of data. Over the course of the survey approximately 71% of the sample was very satisfied, satisfied or neither satisfied nor dissatisfied with publicly funded dental services. Satisfaction fell at the outset of the study period but rose following the economic downturn from 2008 which coincided with increased use of publicly funded services. Differences were evident in satisfaction between older versus younger respondents, more affluent versus less affluent respondents and better educated versus less well-educated respondents. Satisfaction did not appear to change in response to policy changes.

Conclusion

Satisfaction is an important outcome of service provision. Policies aiming to improve satisfaction with publicly funded dental care in the UK must take account of the competing demands on dentists’ time from private patients. At times of economic expansion or when supply has been disrupted, these may be particularly acute and require specific interventions to improve access for those who depend on public services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02343-7.

Unlocking the potential of NHS primary care dental datasets

Introduction Maximising the use of routinely collected health data for research is a key part of the UK Government's Industrial Strategy. Rich data are generated by NHS primary care dental services, but the extent of their use in research is unknown.Aims To profile the utility of the post-2006 NHS dental datasets for research, map how they have been used to date and develop recommendations to maximise their utility.Methods The content of and access to the four UK NHS dental datasets was collated using publicly available information and a free-text questionnaire, completed by the relevant data controllers. A scoping review was carried out to identify and map literature that has utilised NHS dental activity data.Results The contents of the UK NHS dental activity datasets are described, alongside how they may be accessed for research. Strengths and weaknesses of these datasets for research are highlighted. The scoping review identified 33 studies which had utilised NHS dental activity data since 2006. We classified 15 as public health practice, 11 as service evaluation and 7 as research.Conclusion In comparision to other NHS activity datasets, it appears that the UK dental datasets have been underutilised for research. We make 11 recommendations on how their utility for research may be increased.

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.

GIS mapping of healthcare practices: do older adults have equitable access to dental and medical care in the UK?

Introduction Considering an ageing population with increasing comorbidities, access to oral and general healthcare is a growing concern. This study aimed to identify and compare access to dental and general practices. This study further aimed to ascertain if there exists a socioeconomic distribution of dental and general practices among older adults.Materials and methods A total of 13,007 dental practices and 13,759 general practices were mapped using geographic information system software, and overlaid with the UK older adult population and deprivation data by health areas. Data analysis was carried out by creating a geographical distribution map and by using descriptive statistics, Gini coefficients and Lorenz curves.Results NHS Central London Clinical Commissioning Group (CCG) held the highest dental practice-to-population ratio of 958 practices per 100,000 older adults, while NHS Manchester CCG held the highest general practice-to-population ratio of 264.4 general practices per 100,000 older adults. England had the highest Gini coefficients for general and dental practice at 0.214 and 0.195, respectively. Both dental and general practices were socioeconomically distributed among older adults in England, Wales and Northern Ireland, but not in Scotland.Conclusions An increasing proportion of older adults need access to healthcare that is based on clinical need, not the ability to pay; a founding principle of the NHS. This nation-wide study captures inequities in the spatial accessibility for older adults in the UK.

Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation

Background

Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry.

Objectives

The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis.

Design

A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study.

Setting

The setting was NHS dental practices in North West England.

Participants

A total of 217 low-risk patients in eight high-street dental practices participated.

Interventions

The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm).

Main outcome measure

The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists.

Results

No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined.

Limitations

The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate.

Conclusions

Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value.

Future work

Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation.

Trial registration

Current Controlled Trials ISRCTN70032696.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Impact of changing provider remuneration on NHS general dental practitioner services in Northern Ireland: a mixed-methods study

Background

Policy-makers wanted to reform the NHS dental contract in Northern Ireland to contain costs, secure access and incentivise prevention and quality. A pilot project was undertaken to remunerate general dental practitioners using a capitation-based payment system rather than the existing fee-for-service system.

Objective

To investigate the impact of this change in remuneration.

Design

Mixed-methods design using a difference-in-difference evaluation of clinical activity levels, a questionnaire of patient-rated outcomes and qualitative assessment of general dental practitioners’ and patients’ views.

Setting

NHS dental practices in Northern Ireland.

Participants

General dental practitioners and patients in 11 intervention practices and 18 control practices.

Interventions

Change from fee for service to a capitation-based system for 1 year and then reversion back to fee for service.

Main outcome measures

Access to care, activity levels, service mix and financial impact, and patient-rated outcomes of care.

Results

The difference-in-difference analyses showed significant and rapid changes in the patterns of care provided by general dental practitioners to patients (compared with the control practices) when they moved from a fee-for-service system to a capitation-based remuneration system. The number of registered patients in the intervention practices compared with the control practices showed a small but statistically significant increase during the capitation period (p < 0.01), but this difference was small. There were statistically significant reductions in the volume of activity across all treatments in the intervention practices during the capitation period, compared with the control practices. This produced a concomitant reduction in patient charge revenue of £2403 per practice per month (p < 0.05). All outcome measures rapidly returned to baseline levels following reversion from the capitation-based system back to a fee-for-service system. The analysis of the questionnaires suggests that patients did not appear to notice very much change. Qualitative interviews showed variation in general dental practitioners’ behaviour in response to the intervention and how they managed the tension between professional ethics and maximising the profits of their business. Behaviours were also heavily influenced by local context. Practice principals preferred the capitation model as it freed up time and provided opportunities for private work, whereas capitation payments were seen by some principals as a ‘retainer fee’ for continuing to provide NHS care. Non-equity-owning associates perceived the capitation model as a financial risk.

Limitations

The active NHS pilot period was only 1 year, which may have limited the scope for meaningful change. The number of sites was restricted by the financial budget for the NHS pilot.

Conclusions

General dental practitioners respond rapidly and consistently to changes in remuneration, but differences were found in the extent of this change by practice and provider type. A move from a fee-for-service system to a capitation-based system had little impact on access but produced large reductions in clinical activity and patient charge income. Patients noticed little difference in the service that they received.

Future work

With changing population need and increasing financial pressure on the NHS, research is required on how to most efficiently meet the expectations of patients within an affordable cost envelope. Work is also needed to identify and evaluate interventions that can complement changes in remuneration to meet policy goals.

Trial registration

Current Controlled Trials ISRCTN29840057.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

A systems approach using the functional resonance analysis method to support fluoride varnish application for children attending general dental practice

BACKGROUND

All children attending General Dental Practice in Scotland are recommended to receive twice-yearly applications of sodium fluoride varnish to prevent childhood caries, yet application is variable. Development of complex interventions requires theorizing and modelling to understand context. This study applies the Functional Resonance Analysis Method (FRAM) to produce a sociotechnical systems model and identify opportunities for intervention to support application.

METHODS

The FRAM was used to synthesise data which were: routine monitoring of fluoride varnish application in 2015/16; a longitudinal survey with practitioners (n = 1090); in-depth practitioner and key informant interviews (n = 43); and a 'world café' workshop (n = 56).

RESULTS

We describe a detailed model of functions linked to application, and use this to make recommendations for system-wide intervention.

CONCLUSIONS

Rigorous research is required to produce accessible models of complex systems in healthcare. This novel paper shows how careful articulation of the functions associated with fluoride varnish application can support future improvement efforts.

A Markov model assessing the impact on primary care practice revenues and patient's health when using mid-level providers, lesson learned from the United Kingdom

OBJECTIVE

To evaluate the cost-effectiveness of using mid-level providers for dental "check-up" examinations and the treatment of caries in different NHS settings in the United Kingdom. Mid-level providers are a broad category that describes non-dentist members of dental teams. This study focused on the potential use of Dental Hygiene Therapists undertaking dental "check-up" examinations and simple restorative treatment, instead of dentists.

METHODS

A Markov model was used to construct the natural history of caries development in adults that visit a dental practice every six months over a five-year period. Three cost perspectives are taken: those borne to dental healthcare providers in England and Wales, Northern Ireland and Scotland. These represent three separate forms of retrospective payment system that are currently in use in the United Kingdom. The cost outcome was the average amount of retained practice earnings required to provide healthcare per patient visit. The health outcome was the average length of time in a cavity-free state and the cost-effectiveness outcome was incremental cost for six months in a cavity-free state.

RESULTS

No statistical difference was found between dentists and mid-level providers in the length of time in a cavity-free state but the use of the latter saved money in all three NHS health system jurisdictions. This ranged from £7.85 (England and Wales) to £9.16 (Northern Ireland) per patient visit ($10.20 to $11.90, respectively) meaning the incremental cost for six month in a cavity-free state ranged from £261.67 ($339.93) in England and Wales to £305.33 ($369.68) in Northern Ireland. Further, changes in baseline assumptions and parameter values did not change mid-level providers being the dominant service intervention.

CONCLUSION

In a time of limited funds for dental services, these results suggest that resources in public funded systems could be saved using mid-level providers in dental practices, without any health risk to patients or capital investment.