Evaluation of the telephone and clinical NHS urgent dental service in Sheffield

OBJECTIVE

Evaluate an NHS in- and out-of-hours urgent dental service (UDS) including both a telephone triage provider (TTP) and a sole clinical provider (CP) using a quality framework.

BASIC RESEARCH DESIGN

Analysis of activity and patient experience data.

MAIN OUTCOME MEASURES

Ratio of volume of services to activity provided; distance and time travelled; appropriateness of referrals and treatments; equity of utilisation; patient experience; cost per patient.

RESULTS

Almost all calls (96.6%) to the TTP were answered within 60 seconds and of people referred to the CP 96.0% needed treatment. Proportionately more people from deprived areas used the TTP. Highest utilisation of the TTP was by people aged 20 to 44 years and lowest was by people over 54 years. Cost per patient utilising the TTP was £5.06. Of the available appointments provided by the CP, 90.9% were booked the TTP. Travel time to the CP was less than 30 minutes for 78.0% of patients. Of treatments provided, 77.9% were clinical interventions and 18.1% were prescription only. Proportionately more people from deprived areas attended the CP. Highest utilisation was by people aged 20 to 44 years and lowest by people over 54 years. Nearly half (47.0%) of those attending reported they did not have a dentist. There was a high level of patient satisfaction. Cost per course of treatment at the CP was £67.41.

CONCLUSION

Overall the UDS provided a high quality service in line with Maxwell's dimensions of quality. Timely advice and treatment was provided with high levels of patient satisfaction with the CP. Comparison with other urgent dental service models would determine the relative efficiency of the UDS.

Oral Healthcare Implications of Mass Migration

Population movements, whether voluntary or forced, are an integral part of an increasingly globalized society and, while the health needs of migrant populations cannot be generalized, some migrants can have worse oral health outcomes compared with their host-country counterparts, with their first dental contact typically being for emergency care. Failure to provide immediately necessary treatment may be unlawful under the Human Rights Act 1998. CPD/Clinical Relevance: NHS dental services need to evolve and address the challenges inherent in caring for vulnerable migrants. Education and appropriate training needs to be developed for the dental profession in order to enable new ways of promoting intersectoral care and community engagement.

Factors influencing the provision of removable partial dentures by dentists in Ireland

Factors influencing clinical treatment of partially dentate patients are varied, and there is a need to identify factors influencing success in the provision of removable partial dentures. The aim of this study was to assess the attitudes of general dental practitioners (GDPs) in Ireland towards tooth replacement and use of RPDs, in partially dentate older adults. The sample frame was the Register of Dentists in Ireland; data were also collected from a sample of dentists practising under NHS regulations in Northern Ireland. Validated questionnaires were sent to all dentists on the Register of Dentists in the Republic of Ireland, and dentists working under NHS regulations registered with the Central Services Agency in Northern Ireland. Content of the questionnaire included details of the dentist themselves, their dental practice and the profile of partial denture provision. They were also asked to give their views on factors influencing the success or failure of an RPD, the process of providing RPDs and their attitudes to RPD provision. A total of 1,143 responses were received, a response rate of 45%. A mean number of 61 RPDs per annum were provided, with 75% of dentures provided being acrylic based. Respondents indicate their belief that cobalt-chromium based dentures had a longer prognosis than acrylic dentures, but less than half (46%) claim to design the frameworks themselves. Patients' attitudes are considered influential in the success of RPD provision, and their influence on appearance is considered the most important factor influencing success. The most important factors influencing failure are: the patient not requesting a denture; an RPD restoring unbounded saddles; and, lower RPDs. Although considered important, approximately 60% of the sample do not routinely organise follow-up appointments for patients provided with RPDs. The fee structures in the DTSS and DTBS are considered a barrier to quality in the provision of partial dentures.

The influence of economic incentives on treatment patterns in a third-party funded dental service

OBJECTIVE

To investigate the response of dental practitioners to administration and remuneration adjustments to the Dental Treatment Services Scheme (DTSS) in the Republic of Ireland.

DESIGN

Following the introduction of a series of administration and fee adjustments by a third party payments system in December 1999 the pattern of extractions and restorations are examined to determine whether the adjustments had influenced provider behaviour, in particular whether a substitution effect from extractions to restorations would result from a relative fee increase of 62% for amalgam fillings.

DATA AND METHODS

Data on patient and provider characteristics from June 1996 to April 2005, collected by the Health Service Executive (HSE) National Shared Services Primary Care Reimbursement Service to facilitate remuneration to dentists providing services in the DTSS, was used in this analysis. A graphical analysis of the data revealed a structural break in the time-series and an apparent substitution to amalgam fillings following the introduction of the fee increases. To test the statistical significance of this break, the ratio of amalgams to restorations was regressed on the trend, growth and level dummy variables, using Ordinary Least Squares (OLS) regression. The diagnostics of the model were assessed using the Jarque-Bera normality test and the LM to test for serial correlation.

RESULTS

The initial results showed no evidence of a structural break. However on further investigation, when a pulse dummy was included to account for the immediate impact of the fee adjustment the results suggest a unit root process with a structural break in December 1999. This implies that the amalgam fee increase of December 1999 influenced the behaviour patterns of providers.

CONCLUSIONS

System changes can be used to change the emphasis from a scheme that was principally exodontia/emergency based to a scheme that is more conservative and based on restoration/prevention.

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.

Measurement of attitudes of U.K. dental practitioners to core job constructs

OBJECTIVES

To develop a measure to identify dental practitioner attitudes towards core job dimensions relating to job satisfaction and motivation and to test this against practice characteristics and provider attributes of U.K. practitioners.

RESEARCH DESIGN

an 83-item questionnaire was developed from open-ended interviews with practitioners and use of items in previously used dentist job satisfaction questionnaires. This was subsequently sent to 684 practitioners. Item analysis reduced the item pool to 40 items and factor analysis (PCA) was undertaken.

RESULTS

440 (64%) dentists responded. Factor analysis resulted in six factors being identified as distinguishable job dimensions, overall Cronbach's alpha = 0.88. The factors were: 'restriction in being able to provide quality care (F1)', 'respect from being a dentist (F2)', 'control of work (F3)', 'running a practice (F4)', 'clinical skills (F5)', and 'caring for patients (F6)'. All six factors were correlated with a global job satisfaction score, although F1 was most strongly related (r = 0.60). Regression model analysis revealed that 'whether the dentist worked within the National Health Service or wholly or partly in the private sector' (p < 0.001), 'time since qualification' (p = 0.009), and the position of the dentist within the practice (whether a practice owner or associate dentist), (p = 0.047) were predictive of this factor.

CONCLUSIONS

Six core job constructs of U.K. practitioners have been identified, together with several practice characteristics and practitioner attributes which predict these factors. The study demonstrates the importance of refining measures of dentists' job satisfaction to take account of the culture and the system in which the practitioner works.

Reforming NHS dentistry

Equitable distribution of affordable dental services is still possible

NHS dentistry in the United Kingdom: past, present and future. A personal view

The National Health Service (NHS) was created in 1948 to provide both medical and dental healthcare for the UK resident population based on need, not the ability to pay. Between 1948 and 2006 NHS dentistry improvement in oral health of the has made a huge contribution to the population of the UK.

A fistful of UDAs

One year in and we are now starting to see the truth behind the new contract, which was hailed as the saviour of NHS dentistry. Despite words of comfort and reassurance from the CDO, the majority of dentists seem ill at ease with their lot. There are mutterings in the ranks; there are concerned whispers about UDA values and 2009. They huddle in their surgeries, worrying about the financial implications of their underperformance. PCTs, short of money are only now being given the data by the BSA about how well their dentists have done. Many are not happy with what they see. This article looks at where we are now, and gives a personal view on how we got here.

Attitudes and practice in the provision of removable partial dentures

OBJECTIVE

To identify the factors shaping the pattern of removable partial denture (RPD) provision by dentists in England. Design Cross sectional survey of general dental practitioners.

METHODS

Details of current practice and provision, influences, attitudes and demographic details were collected using a self-completion questionnaire mailed to general dental practitioners identified through the Dental Practice Board register.

RESULTS

Three hundred and eighty-five questionnaires were returned by general dental practitioners from 62 health authorities throughout England. The most important factor reported as influencing both the GDP's decision to provide a partial denture and its subsequent success was patient desire to have a partial denture. Constructing the denture from cobalt chrome, advising the patient on aftercare, making time available to make minor adjustments and being responsible for design were all factors dentists associated with success of a RPD. However, for a number of dentists there was a reported divergence between knowledge and practice.

CONCLUSION

Overall it is clear that provision of partial dentures continues to be patient led. However, the decision making process is also influenced by a number of factors including time, cost and the NHS fee structure.

Cost-effectiveness and patient satisfaction: Hawley and vacuum-formed retainers

In the United Kingdom (UK) over the last 10 years, there has been a significant increase in the use of vacuum-formed retainers (VFRs) rather than conventional Hawley retainers. There are currently no data to compare the cost-effectiveness of this change in practice. The two aims of this study were to compare (1) the cost-effectiveness of VFRs and Hawley retainers over 6 months, from the perspective of the National Health Service, orthodontic practice, and the patient and (2) patient satisfaction in the two retainer groups. A randomized controlled trial (RCT) was carried out in a specialist orthodontic practice. Three hundred and ninety-seven eligible patients were randomized to one of two retainer groups, and followed up for 6 months. All subjects were invited to complete patient satisfaction questionnaires. Additional data were collected for the cost analysis from the patient records and national databases. Descriptive and bivariate analyses were used to compare patient satisfaction between retainer groups. In all, 196 subjects were randomized to the Hawley group (mean age 14 years 8 months, 63 per cent female, 37 per cent male) and 201 to the VFR group (mean age 15 years, 59 per cent female, 41 per cent male). VFRs were more cost-effective than Hawley retainers from all perspectives. The majority of subjects showed a preference for VFRs compared with Hawley retainers. There were also fewer breakages than in the Hawley group.

Perceptions and Attitudes to a Fundamental Reform of General Dental Services in Wales

Background

The greatest reform of state-funded dental care in England and Wales, since the inception of the National Health Service (NHS) in 1948, occurred on 1st April 2006. It encompassed the dissolution of a universal national contract and the introduction of locally commissioned primary dental care services in England and Wales. Suggested advantages included the elimination of the fee-for-item-of-service ‘treadmill’, an increased emphasis on prevention, and improved access—at a time when many practitioners were opting to provide care outside the NHS system.

Objectives

This study investigated the perceptions and attitudes to the new contract, in the three months immediately prior to its implementation.

Methodology

Data were collected via a postal questionnaire, comprising a combination of 56 closed and open questions. The questionnaire was mailed to all general dental practitioners in Wales.

Results

691 (64.5%) questionnaires were returned. Just 140 (23%) dentists agreed or strongly agreed that they would have more time to spend with patients under the new contract. The majority of respondents, 361 (59.3%), disagreed that they would be able to spend more time on prevention. Three hundred and sixty-six (60.2%) disagreed that they were strongly attracted by the new method of remuneration and only 62 (10.2%) perceived a reduced level of administration. Of the 608 dentists who provided NHS dental services, 418 (68.6%) indicated they would continue to do so, 130 (21.4) were undecided, and 55 (9%) stated that they would not take up the new contract. Allowing for the number of days worked per week and the percentage time spent on NHS patients, these equate to 72.3%, 21% and 5.9% of NHS capacity respectively.

Conclusions

This study has established baseline perceptions of reform in state-funded dental care in Wales. As the new contract evolves, it will be interesting to determine whether the largely negative perceptions of new ways of working expressed in this study are realised.

Orthognathic treatment: how much does it cost?

The aim of this multi-centre retrospective study was to assess the cost, and factors influencing the cost, of combined orthodontic and surgical treatment for dentofacial deformity. The sample, from the south-west of England, comprised 352 subjects (109 males and 243 females) with an age range of 14 to 57 years treated in 11 hospital orthodontic units. Treatment costs were calculated for each subject by combining consumable costs with staff overhead and capital costs. The median total treatment cost was euro 6075.25 (interquartile range: euro 5139.41-euro 7069.68). Out-patient costs comprised 43 per cent. The median orthodontic treatment costs were euro 1456.23 (interquartile range: euro 1283.73-euro 1638.75). Orthodontic costs on average comprised 25 per cent of the total treatment cost. The cost of orthodontics for orthognathic patients in a hospital setting appears to represent excellent value for the state funded National Health Service in the United Kingdom.

A dental workforce review for a Midlands Strategic Health Authority

OBJECTIVE

To explore opportunities for workforce development in NHS general dental services (GDS) in Shropshire and Staffordshire.

METHOD

Secondary data sources were supplemented with a primary survey of GDS practices to build up a profile of the existing GDS workforce and its current capacity. Attitudes and perceptions on current workforce issues and potential solutions were gathered using a second survey and explored further through other qualitative techniques including interviews and a focus group discussion.

RESULTS

The results confirm that there is a shortage of dentists in the area, fuelled by multiple factors including the move from NHS to private work, the decision to retire early and a growing disillusionment with NHS policies and remuneration. Modelling of alternate approaches to future dental clinical needs highlighted the opportunity for meeting the consequent workforce demands through increased involvement of hygienists and therapists.

CONCLUSIONS

This study has provided local evidence to inform dental service development in Shropshire and Staffordshire. It has provided a starting point for exploring new ways of working and will contribute towards a more effective implementation of new and evolving service strategies.

Why do dentists struggle with removable partial denture design? An assessment of financial and educational issues

AIM

Published studies in the international dental literature illustrate that the quality of prescription and fabrication of cobalt-chromium removable partial dentures (CCRPDs) by general dental practitioners frequently fail to comply with ethical and legal requirements. The reasons cited for this in the past have broadly related to either financial or educational issues. The aim of this investigation is to determine the effect of financial and educational factors on the quality of CCRPD design and fabrication by general dental practitioners.

MATERIALS AND METHODS

This investigation was completed in two parts. (1) A pre-piloted pro-forma was distributed to a number of dental laboratories throughout the UK and Ireland. These sought information relating to the quality of written instructions for CCRPDs received by these laboratories, and details of the remunerative scheme under which they were being provided. Three categories of remunerative scheme were considered, private CCRPDs in Ireland, private CCRPDs in the UK, and CCRPDs being provided by salaried NHS practitioners. (2) A pre-piloted questionnaire was distributed to vocational dental practitioners in the UK and Ireland. This sought information relating to their attitudes, opinions, and educational and clinical experiences of CCRPD design and fabrication.

RESULTS

(1) Three hundred completed pro-formas were returned from dental laboratories, 100 of which related to each of the three remunerative schemes. Poor or no written instructions were provided in 47% (n = 47) of CCRPD cases funded privately in the UK, 46% (n = 46) of CCRPD cases funded privately in Ireland, and 50% (n = 50) of CCRPDs being provided by salaried NHS practitioners. (2) One hundred and seven completed questionnaires were returned from vocational trainees. Vocational dental practitioners had completed fewer CCRPDs during VT than in dental school (dental school: median = 4, inter-quartile range = 3 to 5; VT: median = 2, inter-quartile range = 1 to 4). One-fifth of respondents (n = 22) had not completed any CCRPDs during VT. Nine per cent of VT practices (n = 10) had a surveyor on their premises. Only 15% (n = 16) of respondents felt the time they had spent in VT had increased their confidence in the design of CCRPDs.

CONCLUSION

Financial factors did not have as significant an effect on the quality of prescription and fabrication of CCRPDs as did educational factors. Serious deficiencies in the teaching of CCRPDs during vocational training were identified.

Determining 'need' for a Removable Partial Denture: a qualitative study of factors that influence dentist provision and patient use

OBJECTIVE

To identify factors that influence Removable Partial Denture (RPD) provision, and patient use of RPDs in the UK.

DESIGN

Exploratory qualitative interview study.

SUBJECTS AND METHODS

SUBJECTS

There were two sample groups. A purposive sample of 16 male and female dentists was categorised in terms of level of RPD provision, experience, and practice characteristics. A purposive sample of 17 male and female partially dentate patients was categorised in terms of RPD use and demographic characteristics.

DATA COLLECTION

Semi-structured in-depth interviews.

RESULTS

For dentists, RPD provision was indicated by patient demand and physical function of the remaining teeth, but was mediated by NHS fee structures and professional satisfaction. For patients, RPD use was influenced by the trade-off between improved appearance and the unpalatable presence of an RPD in their mouth. The location of the gap(s) was important, but other issues were relevant such as ability to "manage" without the RPD.

CONCLUSION

When defining "need" for an RPD, dentists focused on physical function of the teeth whereas patients focused on social meanings of the mouth. These differing priorities may improve understandings of patient non-compliance in RPD use. Further research on the relationship between denture use and social identity could be beneficial.

Salaried services in the delivery of dental care in Western industrialised countries: implications for the National Health Service in England

OBJECTIVE

To examine the provision of dental services by salaried personnel in the countries of Western Europe, together with Australia, Canada and New Zealand, and to weigh the merits of this method against alternatives, namely, capitation and fee for item of service. In light of the findings, to consider the future role of salaried dental services in the National Health Service (NHS) in England.

METHOD

Information was gathered from published reports, the World Wide Web and by mailed questionnaire to national chief dental officers or equivalents.

RESULTS

Narrative descriptions of service provision in the countries with salaried primary dental care services were compiled. Demographic, macro-economic, workforce, and oral health data for the broader spectrum of Western industrialised countries were tabulated. Examination of the quantitative data showed no strong associations between variables.

CONCLUSIONS

Dental services delivered by a salaried workforce can be costly in relation to the volume of clinical activity produced. However, deployment of clinical auxiliary personnel can keep costs down. Salaried services foster a preventive approach to care and are particularly suitable where care is directed towards vulnerable groups within the community. Salaried staff generally receive a lower level of remuneration than private practitioners but usually work in an environment less subject to undue pressures of time.