Unethical aspects of homeopathic dentistry

In the last year there has been a great deal of public debate about homeopathy, the system of alternative medicine whose main principles are that like cures like and that potency increases relative to dilution. The House of Commons Select Committee on Science and Technology concluded in November 2009 that there is no evidence base for homeopathy, and agreed with some academic commentators that homeopathy should not be funded by the NHS. While homeopathic doctors and hospitals are quite commonplace, some might be surprised to learn that there are also many homeopathic dentists practising in the UK. This paper examines the statements made by several organisations on behalf of homeopathic dentistry and suggests that they are not entirely ethical and may be in breach of various professional guidelines

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

"7/12" patient touch point strategy: a novel method to increase patient attendance and recommendation.

The US dental system is not likely to see major expansions in dental care use in the foreseeable future. The rise of dental care utilization among low-income children as well as wealthy seniors did not offset flat dental utilization among adults since the Great Recession. Similarly in Spain, the increase in the number of dental practitioners surpasses the rate of population growth. Hence, in order to remain economically viable in this competitive market, one important aspect for every dental office is to retain patients besides attracting new ones. Patients may be lost to follow-up due to a number of factors, including a lack of attention from the dental practice or a lack of trust in the provider. The "7/12" patient touch point strategy of marketing builds consumer loyalty as a result of a strong patient-provider relationship. Furthermore, this method aims to facilitate the patient's decision to visit their dentist when it is time for preventative treatments. The purpose of this study was to measure the efficacy of a "7/12" patient touch point strategy when compared to the traditional annual recall with respect to number of active patients, percentage of word-of-mouth-recommended patients, and overall number of first-visit patients. We executed the relationship marketing concept through a novel "7/12" patient touch point approach, in which the patient was exposed to seven separate exposures in a period of 12 months. The efficacy of the "7/12" patient touch point was analyzed for 48 months across 10 clinics (24 months before and 24 months after the "7/12" strategy implementation). The "7/12" patient touch point strategy resources consisted of online and printed materials with a focus on oral health knowledge. fter analyzing the efficacy of the "7/12" patient touch point, we found an average increase of 86.91% in the number of active patients, 24.12% in the number of word-of-mouth-recommended patients, and 38.05% in the number of first visits across all clinics. This novel "7/12" patient touch point approach may be successful in increasing the retention of existing patients and generating new patients. Furthermore, this method promotes preventative care and oral health maintanance for patients and economic progress for the dental clinic

Competition in Primary Healthcare in Ireland:More and Better Services for Less Money

Understanding precisely the nature of competition in primary healthcare has an important role to play in understanding how to improve the delivery of healthcare services. This is particularly the case in Ireland, where the private sector plays such a large role in primary care. If we do not understand competition, well-intentioned regulations and policies are less likely to be effective and more likely to result in excessive costs and under-utilisation of primary healthcare. This in turn can increase Ireland’s overall health expenditure and contribute to a higher cost of living in Ireland and thus lower competitiveness. This paper shows how well-designed regulations and systems for State funding of primary healthcare can ensure that competition works well and contributes to the better availability and quality of services at the lowest possible cost. The most common barriers to entry and expansion in primary healthcare markets are outlined and pricesetting mechanisms examined. Examples are used to illustrate the benefits to consumers and the State where these obstacles to competition have been removed, and the difficulties where they remain. Conclusions are drawn on the implications of this analysis for the governance of regulatory bodies, for regulatory Codes of Conduct, and for achieving value for money. It is time for the culture of the healthcare professions to move towards one where it is no longer considered “unprofessional” to provide a competitive service.

Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study

Background: Previous research suggests that non-obstetric surgery is carried out in 1 – 2% of all pregnancies. However, there is limited evidence quantifying the associated risks. Furthermore, of the evidence available, none relates directly to outcomes in the UK, and there are no current NHS guidelines regarding non-obstetric surgery in pregnant women. Objectives: To estimate the risk of adverse birth outcomes of pregnancies in which non-obstetric surgery was or was not carried out. To further analyse common procedure groups. Data Source: Hospital Episode Statistics (HES) maternity data collected between 2002 – 3 and 2011 – 12. Main outcomes: Spontaneous abortion, preterm delivery, maternal death, caesarean delivery, long inpatient stay, stillbirth and low birthweight. Methods: We utilised HES, an administrative database that includes records of all patient admissions and day cases in all English NHS hospitals. We analysed HES maternity data collected between 2002 – 3 and 2011 – 12, and identified pregnancies in which non-obstetric surgery was carried out. We used logistic regression models to determine the adjusted relative risk and attributable risk of non-obstetric surgical procedures for adverse birth outcomes and the number needed to harm. Results: We identified 6,486,280 pregnancies, in 47,628 of which non-obstetric surgery was carried out. In comparison with pregnancies in which surgery was not carried out, we found that non-obstetric surgery was associated with a higher risk of adverse birth outcomes, although the attributable risk was generally low. We estimated that for every 287 pregnancies in which a surgical operation was carried out there was one additional stillbirth; for every 31 operations there was one additional preterm delivery; for every 25 operations there was one additional caesarean section; for every 50 operations there was one additional long inpatient stay; and for every 39 operations there was one additional low-birthweight baby. Limitations: We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Many spontaneous abortions will not be associated with a hospital admission and, therefore, will not be included in our analysis. A spontaneous abortion may be more likely to be reported if it occurs during the same hospital admission as the procedure, and this could account for the associated increased risk with surgery during pregnancy. There are missing values of key data items to determine parity, gestational age, birthweight and stillbirth. Conclusions: This is the first study to report the risk of adverse birth outcomes following non-obstetric surgery during pregnancy across NHS hospitals in England. We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Our observational study can never attribute a causal relationship between surgery and adverse birth outcomes, and we were unable to determine the risk of not undergoing surgery where surgery was clinically indicated. We have some reservations over associations of risk factors with spontaneous abortion because of potential ascertainment bias. However, we believe that our findings and, in particular, the numbers needed to harm improve on previous research, utilise a more recent and larger data set based on UK practices, and are useful reference points for any discussion of risk with prospective patients. The risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery is relatively low, confirming that surgical procedures during pregnancy are generally safe. Future work: Further evaluation of the association of non-obstetric surgery and spontaneous abortion. Evaluation of the impact of non-obstetric surgery on the newborn (e.g. neonatal intensive care unit admission, prolonged length of neonatal stay, neonatal death). Funding: The National Institute for Health Research Health Services and Delivery Research programme