Alternative scenarios: harnessing mid-level providers and evidence-based practice in primary dental care in England through operational research

Background: In primary care dentistry, strategies to reconfigure the traditional boundaries of various dental professional groups by task sharing and role substitution have been encouraged in order to meet changing oral health needs. Aim: The aim of this research was to investigate the potential for skill mix use in primary dental care in England based on the undergraduate training experience in a primary care team training centre for dentists and mid-level dental providers. Methods: An operational research model and four alternative scenarios to test the potential for skill mix use in primary care in England were developed, informed by the model of care at a primary dental care training centre in the south of England, professional policy including scope of practice and contemporary evidence-based preventative practice. The model was developed in Excel and drew on published national timings and salary costs. The scenarios included the following: “No Skill Mix”, “Minimal Direct Access”, “More Prevention” and “Maximum Delegation”. The scenario outputs comprised clinical time, workforce numbers and salary costs required for state-funded primary dental care in England. Results: The operational research model suggested that 73% of clinical time in England’s state-funded primary dental care in 2011/12 was spent on tasks that may be delegated to dental care professionals (DCPs), and 45- to 54-year-old patients received the most clinical time overall. Using estimated National Health Service (NHS) clinical working patterns, the model suggested alternative NHS workforce numbers and salary costs to meet the dental demand based on each developed scenario. For scenario 1:“No Skill Mix”, the dentist-only scenario, 81% of the dentists currently registered in England would be required to participate. In scenario 2: “Minimal Direct Access”, where 70% of examinations were delegated and the primary care training centre delegation patterns for other treatments were practised, 40% of registered dentists and eight times the number of dental therapists currently registered would be required; this would save 38% of current salary costs cf. “No Skill Mix”. Scenario 3: “More Prevention”, that is, the current model with no direct access and increasing fluoride varnish from 13.1% to 50% and maintaining the same model of delegation as scenario 2 for other care, would require 57% of registered dentists and 4.7 times the number of dental therapists. It would achieve a 1% salary cost saving cf. “No Skill Mix”. Scenario 4 “Maximum Delegation” where all care within dental therapists’ jurisdiction is delegated at 100%, together with 50% of restorations and radiographs, suggested that only 30% of registered dentists would be required and 10 times the number of dental therapists registered; this scenario would achieve a 52% salary cost saving cf. “No Skill Mix”. Conclusion: Alternative scenarios based on wider expressed treatment need in national primary dental care in England, changing regulations on the scope of practice and increased evidence-based preventive practice suggest that the majority of care in primary dental practice may be delegated to dental therapists, and there is potential time and salary cost saving if the majority of diagnostic tasks and prevention are delegated. However, this would require an increase in trained DCPs, including role enhancement, as part of rebalancing the dental workforce

Inequalities in availability of National Health Service general dental practitioners in England and Wales.

AIM: To model the inequalities in availability of National Health Service general dental practitioners in England and Wales in relation to key socio-demographic factors. METHODS: Current estimates of the numbers of NHS general dental practitioners for each health authority were related to data from the 1991 census using Poisson regression models, and generalised estimating equations to allow for correlation between results for neighbouring health authorities. RESULTS: An 'average' health authority, without a dental school, would be expected to have 2,138 residents for every NHS dentist. Controlling for relevant factors, health authorities with higher proportions of the following are associated with lower (better) population to dentist ratios by the amounts shown: each 1% higher female population (-11.8%; 95%CI -19.1%, -3.9% P = 0.004); each 1% greater South Asian population (-1.4%; 95%CI -2.1%, -0.7% P <0.001). A health authority with a dental school is associated with a more favourable ratio compared with one without such a facility (-9.2%; 95%CI -16.2%, -1.6% P = 0.019). Each additional 1% of the following are associated with a worse ratio by the amounts shown: children aged 0 to 14 years old (+5.2%; 95% CI +2.4%, +8.1% P < 0.001); adults aged over 65 years old (+2.8%, 95%CI +1.0%, +4.7% P =0.002); households without a car (+0.8%; 95%CI 0.0%, +1.6% P =0.042). CONCLUSIONS: Ensuring access to dental care may be a more complex issue than simply providing adequate numbers of dentists at a national level. Any manpower planning exercise should additionally consider local factors that may act as incentives or disincentives to those professionals who provide care