National evaluation of personal dental services (PDS) pilots: main findings and policy implications

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.

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.

The INCENTIVE study: a mixed-methods evaluation of an innovation in commissioning and delivery of primary dental care compared with traditional dental contracting

Background

Over the past decade, commissioning of primary care dentistry has seen contract currency evolving from payment for units of dental activity (UDAs) towards blended contracts that include key performance indicators such as access, quality and improved health outcome.

Objectives

The aim of this study was to evaluate a blended/incentive-driven model of dental service provision. To (1) explore stakeholder perspectives of the new service delivery model; (2) assess the effectiveness of the new service delivery model in reducing the risk of and amount of dental disease and enhancing oral health-related quality of life (OHQoL) in patients; and (3) assess cost-effectiveness of the new service delivery model.

Methods

Using a mixed-methods approach, the study included three dental practices working under the blended/incentive-driven (incentive) contract and three working under the UDAs (traditional) contract. All were based in West Yorkshire. The qualitative study reports on the meaning of key aspects of the model for three stakeholder groups [lay people (patients and individuals without a dentist), commissioners and the primary care dental teams], with framework analysis of focus group and semistructured interview data. A non-randomised study compared clinical effectiveness and cost-effectiveness of treatment under the two contracts. The primary outcome was gingivitis, measured using bleeding on probing. Secondary outcomes included OHQoL and cost-effectiveness.

Results

Participants in the qualitative study associated the incentive contract with more access, greater use of skill mix and improved health outcomes. In the quantitative analyses, of 550 participants recruited, 291 attended baseline and follow-up. Given missing data and following quality assurance, 188 were included in the bleeding on probing analysis, 187 in the caries assessment and 210 in the economic analysis. The results were mixed. The primary outcome favoured the incentive practices, whereas the assessment of caries favoured the traditional practices. Incentive practices attracted a higher cost for the service commissioner, but were financially attractive for the dental provider at the practice level. Differences in generic health-related quality of life were negligible. Positive changes over time in OHQoL in both groups were statistically significant.

Limitations

The results of the quantitative analysis should be treated with caution given small sample numbers, reservations about the validity of pooling, differential dropout results and data quality issues.

Conclusions

A large proportion of people in this study who had access to a dentist did not follow up on oral care. These individuals are more likely to be younger males and have poorer oral health. Although access to dental services was increased, this did not appear to facilitate continued use of services.

Future work

Further research is required to understand how best to promote and encourage appropriate dental service attendance, especially among those with a high level of need, to avoid increasing health inequalities, and to assess the financial impact of the contract. For dental practitioners, there are challenges around perceptions about preventative dentistry and use of the risk assessments and care pathways. Changes in skill mix pose further challenges.

Funding

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

Contracting with General Dental Services: a mixed-methods study on factors influencing responses to contracts in English general dental practice

Background

Independent contractor status of NHS general dental practitioners (GDPs) and general medical practitioners (GMPs) has meant that both groups have commercial as well as professional identities. Their relationship with the state is governed by a NHS contract, the terms of which have been the focus of much negotiation and struggle in recent years. Previous study of dental contracting has taken a classical economics perspective, viewing practitioners’ behaviour as a fully rational search for contract loopholes. We apply institutional theory to this context for the first time, where individuals’ behaviour is understood as being influenced by wider institutional forces such as growing consumer demands, commercial pressures and challenges to medical professionalism. Practitioners hold values and beliefs, and carry out routines and practices which are consistent with the field’s institutional logics. By identifying institutional logics in the dental practice organisational field, we expose where tensions exist, helping to explain why contracting appears as a continual cycle of reform and resistance.

Aims

To identify the factors which facilitate and hinder the use of contractual processes to manage and strategically develop General Dental Services, using a comparison with medical practice to highlight factors which are particular to NHS dental practice.

Methods

Following a systematic review of health-care contracting theory and interviews with stakeholders, we undertook case studies of 16 dental and six medical practices. Case study data collection involved interviews, observation and documentary evidence; 120 interviews were undertaken in all. We tested and refined our findings using a questionnaire to GDPs and further interviews with commissioners.

Results

We found that, for all three sets of actors (GDPs, GMPs, commissioners), multiple logics exist. These were interacting and sometimes in competition. We found an emergent logic of population health managerialism in dental practice, which is less compatible than the other dental practice logics of ownership responsibility, professional clinical values and entrepreneurialism. This was in contrast to medical practice, where we found a more ready acceptance of external accountability and notions of the delivery of ‘cost-effective’ care. Our quantitative work enabled us to refine and test our conceptualisations of dental practice logics. We identified that population health managerialism comprised both a logic of managerialism and a public goods logic, and that practitioners might be resistant to one and not the other. We also linked individual practitioners’ behaviour to wider institutional forces by showing that logics were predictive of responses to NHS dental contracts at the dental chair-side (the micro level), as well as predictive of approaches to wider contractual relationships with commissioners (the macro level).

Conclusions

Responses to contracts can be shaped by environmental forces and not just determined at the level of the individual. In NHS medical practice, goals are more closely aligned with commissioning goals than in general dental practice. The optimal contractual agreement between GDPs and commissioners, therefore, will be one which aims at the ‘satisfactory’ rather than the ‘ideal’; and a ‘successful’ NHS dental contract is likely to be one where neither party promotes its self-interest above the other. Future work on opportunism in health care should widen its focus beyond the self-interest of providers and look at the contribution of contextual factors such as the relationship between the government and professional bodies, the role of the media, and providers’ social and professional networks.

Funding

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

Conundrums in health care reform: current experiences across the North Atlantic

OBJECTIVE

To assist stakeholders (policy makers, dentists and patients) implementing the Patient Protection and Affordable Care Act of 2010 in the United States by providing information on conundrums arising from previous policies of the UK Labour government and emergent policies of the recently elected Coalition Government.

METHODS

The authors provide a background to the development of National Health Service dental services contrasted with US provision. Considerations are given from the different perspectives of stakeholders involved (policy makers, dentists, and patients).

CONCLUSIONS

Policy makers must work under pressure for services to remain within boundaries of finite economic resources and what people are willing to pay for. The importance is stressed that they respond to public demands and workforce capability by clearly determining what the priorities should be, what services will be delivered, and defining responsibilities.

Public policy and the market for dental services

Social inequality in access to oral health care is a feature of countries with predominantly privately funded markets for dental services. Private markets for health care have inherent inefficiencies whereby sick and poor people have restricted access compared to their healthy and more affluent compatriots. In the future, access to dental care may worsen as trends in demography, disease and development come to bear on national oral healthcare systems. However, increasing public subsidies for the poor may not increase their access unless availability issues are resolved. Further, increasing public funding runs counter to policies that feature less government involvement in the economy, tax policy on private insurance premiums, tax reductions and, in some instances, free-trade agreements. We discuss these issues and provide international examples to illustrate the consequences of the differing public policies in oral health care. Subsidization of the poor by inclusion of dental care in social health insurance models appears to offer the most potential for equitable access. We further suggest that nations need to develop national systems capable of the surveillance of disease and human resources, and of the monitoring of appropriateness and efficiency of their oral healthcare delivery systems.

Managing resources in NHS dentistry: the views of decision-makers in primary care organisations

OBJECTIVE

To investigate priority setting and decision-making in primary care organisations and to determine how resources are managed in order to meet the oral health needs of local populations.

METHOD

This is a qualitative study. The purposive sample comprised twelve dental public health consultants and six senior finance representatives from contrasting care systems across the United Kingdom. Participants completed a written information sheet followed by a recorded semi-structured telephone interview. Conversations were professionally transcribed verbatim and analysed independently by two investigators using the constant comparative method.

RESULTS

The emergent themes focused upon: the role of participants in decision-making; professional relationships; managing change; information needs; and identifying and managing priorities. There was wide interpretation with respect to participants' roles and perceived information needs for decision-making and commissioning. A unifying factor was the importance placed by participants upon trust and the influence of individuals on the success of relationships forged between primary care organisations and general dental practitioners.

CONCLUSION

To facilitate decision-making in primary care organisations, commissioners and managers could engage further with practitioners and incorporate them into commissioning and resource allocation processes. Greater clarity is required regarding the role of dental public health consultants within primary care organisations and commissioning decisions.

A Survey to Investigate Shortfalls in the Dental Care Professional (DCP) Workforce in South Yorkshire in 2004

Aim

To determine the composition of the dental care professional (DCP) workforce in South Yorkshire, the existence of any training requirements, and future intentions and motivations relating to the provision of National Health Service (NHS) dental care.

Methods

The study used mixed methods and incorporated a cross-sectional postal questionnaire and focus groups. The questionnaire was sent to all NHS dental practices in South Yorkshire (n=201) for completion by a principal general dental practitioner (GDP). Focus groups were held with GDPs in these practices.

Results

Responses were received from principal GDPs at 156 practices (78%). A total of 624 dental nurses, 65 dental hygienists and 24 dental therapists were employed in the responding General Dental Services (GDS) practices, representing whole-time equivalents (WTEs) of 458.5, 18.5 and 10.1, respectively. Many practices had current vacancies for DCPs, with 24.9 WTE available for dental nurses, 3.7 WTE for dental hygienists, and 5.0 WTE for dental therapists. Workforce shortages were evident among dental nurses (5.2%), dental hygienists (16.7%), and dental therapists (33.0%). Principal GDPs suggested that improved terms and conditions of employment for DCPs, particularly dental nurses, might aid recruitment and retention in NHS practice.

Conclusions

Respondents perceived that there were shortages in the DCP workforce in South Yorkshire. Initiatives are required to address these shortages.

A qualitative analysis of the planning, implementation and management of a PDS scheme: lessons for local commissioning of dental services

AIM

To identify the experiences of primary care trust employees, the dental teams and other key individuals of the planning, implementation and management of a Personal Dental Services scheme.

METHOD

A thematic analysis of a series of qualitative interviews with 29 individuals who were involved in the planning, implementation and management of a PDS scheme in South East London.

FINDINGS

Nine key themes were analysed from the data. For each theme perspectives could be identified for both the employees of the primary care trusts and the dental team. These perspectives differ in key respects.

CONCLUSIONS

Practitioners value the PDS scheme and consider it a positive experience. They suggest that it has led to an increase in quality of care, and a more professional management approach to the practice. The practice team felt that they have benefited from an enhanced working environment. The main concern expressed was that patient registrations were not being accurately assessed. Those involved in the management of the PDS scheme, while endorsing local commissioning arrangements, were concerned that it was not known whether PDS was meeting local needs. There was little quality benchmarking, which would have allowed robust measure of success. The contract model and outcomes should have been more sensitively designed. There was concern expressed that the small number of practices who participated in the pilot scheme prohibits the possibility of thoroughly analysing the impact of local commissioning. Future local commissioning should identify mechanisms for ensuring the effective planning, management and evaluation of the impact of the schemes. A core element of this will be the specification of appropriate goals for commissioning.

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

Health need and demand are outstripping the capacity of the established professions to provide full and responsive services. In these circumstances attention has turned to the role of allied and complementary professionals in all aspect of health provision, not least dentistry. It is in this context that the role of the dental therapist is coming to be of increasing significance to the dental services.

Patients treated by dental students in outreach: the first year of a pilot project

This paper describes the patients treated by 4th year undergraduate students during the first year of a pilot outreach course to teach Restorative Dentistry in community clinics in 2001-02. Data were collected from 908 summaries of patient treatment completed by the students, and from 139 patient questionnaires. Some 75% of patients were aged between 16 and 64, 58% were female, and 16% had dental phobia or anxiety. Most lived locally to the clinic and 41% made their initial contact as an emergency or drop-in. Some 37% made only a single visit (including children treated as emergencies) but 22% made six or more visits. Did not attend (DNA) was a problem and 18% of patients DNA to complete their treatment. Students undertook the full range of restorative procedures, with the emphasis on direct restorations, preventive treatment and advice, scaling, extractions and emergency treatment. Patients' main reasons for attending the clinic were lay recommendation, the need for treatment, convenience, free treatment, or the lack of access to a dentist. Some 30% said they did not have or did not know of an alternative source of dental care, and half had not seen a dentist for at least 2 years. The study demonstrates that despite difficulties related to attendance, a suitable patient base can be established offering students the opportunity to provide comprehensive care for adults in a primary care setting.