The role of team dentistry in improving access to dental care in the UK

The role of professionals complementary to dentistry (PCDs) in improving access to NHS primary dental care is discussed. The pattern of under-supply of dentists in poor socio-economic areas is highlighted and identified in dra!ing a parallel to the !or"ings of primary medical teams as a possi#le area !here PCDs could #e used.

$ntroduction
There are three major issues that currently face NHS dentistry. Firstly, how do we rectify the widely acknowledged geographical imbalance in the supply and demand for dental services in the !" Secondly, how do we overcome problems of access to NHS primary dental care caused by a significant number of practitioners offering care on a private or private capitation basis, and thirdly, how do we achieve the above within the cash limits imposed by the #overnment" The increased use of professionals complementary to dentistry $%&'s( is seen as a solution to these problems. ) This paper e*plores this supposition, and draws a parallel with changes that have occurred in the last +, years to teams working in primary medical care services. + Top of page

Inequity of dental health and dental care

The -cheson .eport/ reiterated a fact that has been recognised for many years that a close relationship e*ists between poverty and disease in the !. 'ental disease is no e*ception to this rule, with huge variations in levels of disease e*isting between communities. - strong geographical pattern of dental caries prevalence e*ists, with levels lowest in the South, increasing in e*tent and severity towards the North and the 0est.1 Furthermore, an 2inverse care law2 has been seen to operate, where those most in need of medical care are the least likely to receive it. 3 This is also true of access to dental care. &omparing children social classes 45 and 5 with those from social classes 4, 44 and 444 non6manual, almost twice as many children from the lower social classes have actively decayed teeth, even though less than half as many from the lower social classes have ever visited the dentist.7 8ven though there are many economic and psychosocial reasons 9 why people from deprived areas receive comparatively less dental treatment, the relative availability of dentists in the local area does appear to e*plain at least part of the difference in the uptake of treatment. : 0hilst high socio6 economic groups have been shown to often choose dental practices some way from their home, it appears that those from poorer backgrounds are more likely to either use the community dental service $&'S( or a #eneral 'ental %ractice near their home. ; There is some basis for the suggestion that primary dental care services should be sited locally if those from a deprived background are to attend on a regular basis. nfortunately the distribution of general dental practitioners $#'%s( in relation to the dental health levels of children and adults in the ! is markedly ine<uitable. 0hereas, for e*ample, in a ranking of 8nglish health authorities according to dental health e<uity indicators, St Helen2s and !nowsley is ranked only ++=;7 in terms of 2need2 based on #'% to population data, it is ranked in the highest three places for all the #'% to health indicators. ), %rior to analysing potential policies to reduce ine<uality, it first becomes necessary to define 2ine<uality2. The conventional approach based on -ristotle2s principle that e<uals should be treated e<ually and une<uals treated une<ually simply refocuses the problem on what e*actly constitutes e<ual and une<ual 2need2 for dental services. This issue is not as straightforward as it may, at first,

appear and we need to distinguish between concepts of normative need, felt need, e*pressed need and comparative need.)) -re there absolute standards of dental health that should be aspired to $normative need( or should the service be simply responding to patient aspirations $felt need( or patient demands $e*pressed need( or ine<ualities in service receipt $comparative need(" 0hichever definition is adopted, it should reflect the ability of a population to benefit from the provision of dental services and the e*tent to which such potential benefit is synchronised with the supply of dental services within the !. The supply of dental services in the ! has been partly shaped by political and administrative pressures, but is overwhelmingly determined by the individual preferences with regard to practice location e*hibited by dentists. The relatively uneven distribution of #eneral 'ental Services in the ! reflects their status as independent contractors with a freedom to choose where to locate their practice. Top of page

Lack of access to NHS primary dental care

Since the dispute between the government and the profession in );;+ concerning the fee cut, a significant number of #'%s have stopped offering an NHS service. 4nstead they are treating patients on a private basis or under private capitation schemes, sometimes also still continuing to register patients e*empt from NHS charges. This has left a group of people $unable to afford private fees but not <ualifying for e*emptions( unable to access NHS care in the #eneral 'ental Service $#'S(.)+ The proportion of dentists with an NHS commitment of 93> or more has fallen from around 9,> to 7,> since the early );;,s. )/ -gain there is a difference between different regions of the country, with NHS provision in South68ast 8ngland being particularly badly affected. Top of page

Improving accessibility lessons from primary care?

%rimary care teams have become the 2norm2 in primary medical care services but still remain very much the e*ception in primary dental care services. )1 However, it is important to acknowledge that accessibility and e<uity issues currently confronting dentistry mirror those faced by #eneral ?edical %ractice in the recent past. )3 4n order to improve accessibility to #eneral ?edical %ractitioner $#?%( services, two sets of policies were advocated. Firstly, on the supply side, strict controls were enforced on the location decisions of #?%s through a policy of preventing #?%s locating in over6 resourced areas. Secondly, on the demand side, primary care medical teams were developed as a method of e*panding the service provision capacity of individual #?%s and hence e*tending access to primary care in under6resourced areas.)7. The number of practice nurses more than trebled between );:3 and );;))1.The development of teams was also promoted by the move from individual to group practices. Secondly there is the issue of e*panding service provision by the increased use of a team approach. However, #?%s are able to use nurses $albeit statutorily regulated( to innovate without central direction. The system of regulation is significantly different in primary dental care, where there is a listing of duties as a method of regulating %&'s. Nevertheless, the possibility of improving access by an increased use of %&'s in the dental team does warrant closer e*amination. This paper therefore concentrates upon the potential role of primary care dental teams in improving access to NHS dental services in under6resourced locations. Top of page

Primary dental care teams

0hat do we mean by a primary dental care team" The Nuffield Report) defined the dental team as an interchangeable mi* of skills provided by those best suited to e*ercise them by virtue of their training and e*perience. 4n pragmatic terms the dental team is comprised of one or more dentists with a number of other people with lesser training who are able to carry out delegated tasks not re<uiring the full range of the dentists2 skill and e*perience. The vision of primary dental care being

delivered by a dental team is rapidly becoming accepted as the future ideal for primary dental care services in the !. - speech by the ?inister of Health ): at the );;: @'- conference confirmed the #overnment2s commitment to 2encourage dentists as team leaders and provide more opportunities for members of the dental team working under their direction2. The Nuffield 8n<uiry) concluded that the way to e*tend effective primary dental care to a larger proportion of the population without increasing the overall cost of the service was to use 2a differently constituted workforce, running the service more effectively and having au*iliaries providing more skills, including preventive and therapeutic skills2. However, underlying this strategy is an assumption that the use of %&'s in dental teams would enable more people to be seen by %rimary 'ental &are services, but at no e*tra cost to the NHS. ); nfortunately, no evidence is currently available either to support or to refute this assumption. Top of page

ost!effectiveness of P "s
4n the model of the dental team envisaged in this country, a dentist will still undertake all diagnosis and treatment planning as well as comple* treatment outside the remit of other members of the team. Autside the !, %&'s are often allowed to work more independently. The ability to improve efficiency by more accurately e<uating skill level to task comple*ity is therefore potentially enormous. The e*tent of such savings, however, depends not on the comparative cost of dentists and other members of the dental team, but on their 2efficiency wage2 which relates cost to productivity. Thus, if a dentist costs three times as much as a dental hygienist but can treat patients three times as <uickly, then their efficiency wage will be e<uivalent and no savings will arise from substitution. nfortunately, there remains a paucity of information concerning the economic impact of using %&'s in a dental team. Ane -merican study +, evaluated the workload of a dentistB %&' ratio of )B+, )B/ and )B1 respectively. They found that, on average, %&'s took 1,> more time to complete procedures than dentists did and an increased throughput was clearly evident when %&'s were used. 0hen the dentist worked with four %&'s his productivity in terms of dental procedures performed increased from 11 per day $for a dentist working alone assisted by a dental nurse( to ),/ procedures per day. -n e*perimental project based in Condon studied both the cost and productivity of different compositions of dental teams, including one in which %&'s carried out the range of procedures permitted under the ! system and one in which %&'s worked to the remit of the -merican system of e*panded function dental au*iliaries $8F'-(.+) 4t concluded that the dentist working alone was the cheapest way of providing care with %&'s being ),> more e*pensive and 8F'-s being 1,> more e*pensive. However, %&'s were the most productive, with 8F'-s taking +3> more time, and dentists working alone taking 3,> more time to carry out tasks. - cost increase of ),> for a 3,> productivity gain makes %&'s appear a highly cost6effective treatment source for these limited ranges of tasks. -n increase in cost6effectiveness by using %&'s does, however, hinge on the e*istence of an unmet demand for dental services which cannot be met by the dentist=s currently working in the practice. The dentist who diagnoses and treatment plans represents a large fi*ed cost, and although the unit cost of output $ie cost of treating each patient( may be reduced by delegating tasks to people with lesser training and lower pay, there is a limit to such substitution. The dentist either needs to spend the majority of his time doing diagnosis and treatment, or additional more comple* work re<uiring the full range of the dentists2 skill to sustain a significant number of %&'s. ++ -lternatively, %&'s need to work within group practices of several dentists to ma*imise their efficiency. Since in 8ngland and 0ales /7> of #'S practices are run by a single dentist, with a further +7> run by two dentists, and only )+> of practices have five or more dentists working at the same practice address,)/ there are currently only limited situations where %&'s may be used efficiently. #'S workload statistics illustrate the potential for substituting support staff for dentists in the #'S. 4n );;)=;+, out of the +3.7 million items of service completed in the #'S, 11> were a combination of a check6up, diagnosis including an *6ray, and scale and polish. - further /7> were 2routine2 fillings and e*tractions and only 7> involved comple* restorative work such as crowns, inlays, porcelain veneers, bridges.) - comparison with more recent figures from );;9=;: shows that the amount of comple* treatment provision has fallen whilst the amount of simple treatments

has increased.)/ 4f dental therapists were to be able to work in the #'S, they could undertake around /7> of work presently undertaken by dentists. ) Some of the economic benefits of employing %&'s may only be seen in the longterm by increasing the amount of preventive dentistry carried out in the practice. Ane reason for the increased use of dental hygienists in the dental team is that, caused by their professional training, they represent an approach to care directed principally towards prevention. 4n a theoretical model based on the fact that hygienists undertaking dietary advice, topical fluoride application, toothbrushing instruction and prophyla*sis could reduce the caries increment in children and therefore the number of fillings undertaken by the dentist, ?c!endrick found that it was cheaper to carry out preventive measures than for a dentist to treat the resulting disease. +/ -ny consideration of the cost6effectiveness of using %&'s in primary dental care teams must take long term health gain into account. -s such the rationale for introducing %&'s into deprived areas where dental health is poor mirrors what has happened in primary medical care teams, where different health workers working alongside doctors have been able to increase the level of prevention taking place in an attempt to reduce the level of disease in the population and thus the demands on the doctor2s time. +1 Top of page

"iscussion
4n );;9, over +9 million people were registered with a dentist under the #'S, the cost of this to the NHS is around D).7 billion pounds.9 4t is remarkable that even though evidence6based dentistry is now seen as the way forward, evidence6based dental policy6making seems to be lagging somewhat behind. 8ven though it is widely acknowledged that we 2urgently re<uire reliable information on the workforce implications which will result from the redistribution of tasks within the dental team2,+3 as yet none is forthcoming. .esearch is particularly needed to evaluate the impact of %&'s on the accessibility and cost6effectiveness of NHS service provision. .esearch in this area must take ade<uate account of the fact that dental practices vary significantly from each other in the siEe of the team and the way personnel such as dental hygienists are paid. #iven the relatively small siEe of most dental practices, the working practices of each practitioner may significantly affect the work patterns and productivity observed. The type of area in which the practice is situated will also affect the type of treatment offered to the patients on account of variations in patients2 e*pectations and attitudes to dental care. From the available, but very limited evidence, it is possible to ascertain a significant potential role for the development of team dentistry. The proportion of the workload represented by 2routine2 dentistry provides an opportunity to augment the workload supported by dentist by substituting other trained support staff in strictly delineated areas within their competence. The implication of this is that the ability to provide dental care within poorly6resourced areas could be significantly e*panded over the short term without the need to train more dentists or directly interfere in dentists2 practice location decisions. 4n addition, the cost6effectiveness of %&'s in primary dental care may be improved by a move towards larger dental teams. - substantial change will be needed in the way general dental practice is organised in order to support the cost6effective employment of dental therapists. 4t is interesting to observe that in the development of primary care teams in medicine, the siEe of medical practices increased significantly. +7 Top of page

#actors in behaviour
The majority of people living in the very poorest localities attend a dentist in a more affluent area, +9 if they do visit the dentist, demonstrating the lack of a local service. 4t might therefore be supposed that by an increased positioning of dental services in these deprived areas, the demand for dental care would increase, and there is some evidence to support this supposition. : However, other studies show that psychosocial factors also act as determinants when accessing primary dental services,+: and also that barriers to dental attendance e*perienced by deprived populations are not easily modifiable.+; 4n a study of the effect of social and personal factors on the use of dental services in #lasgow, the dental behaviour of respondents living in deprived areas was

significantly affected by life events and yet structural=organisational barriers to attendance had a greater impact on the dental visiting patterns of those from affluent areas. +; Ane could argue that by effectively increasing services in deprived areas by an increased use of %&'s, those who make use of the increased availability may be those who already have access to dental services. 4n other words, the more educated and dentally aware in the community may be the ones who take up the local service. Af course this would just entrench the pattern of ine<uity and e*clusion rather than tackling it. 4t therefore follows that increasing the availability of dental services in a deprived area is a necessary but not sufficient factor in reducing within district ine<ualities. -n e*tension in the provision of service in deprived areas is necessary in order to overcome structural barriers to dental attendance, but may not be sufficient to increase the attendance of the most disadvantaged in the community. %ositive action in terms of health promotion is also re<uired to promote the importance of dental health and the benefits of care among the least aware within the locality. The capacity of %&'s to increase productivity represents a potential solution to the problem of unmet demand for NHS services where e*isting dental manpower has been diverted into providing dental care on a private basis only. @y employing a %&' a dentist could refer on his NHS patients needing routine care, leaving him free to spend time doing comple* treatment, or treating patients on a private basis. The issue concerning whether %&'s represent a more cost6effective approach to the provision of dental services has yet to be resolved, but at least access to NHS primary dental care in these areas will have been restored. The scope for substituting other support staff in certain select areas appears to be substantial. 4t has been established that it is possible to increase productivity with the use of %&'s, and thus %&'s may be particularly useful where there is an unmet demand for dental services. 4f %&'s were permitted to be employed in #'S practices located in deprived and 2under6dentisted2 areas, they may prove to be a valuable resource. -ny financial benefits gained by the employing practitioner could be seen as giving an incentive to locate a dental practice in the area. The issue of substitution and its associated costs and benefits is, however, comple* and relates to an evolving range of staff and tasks in an evolving policy environment. /, There e*ists a paucity of evidence on which to base future development, but a very strong policy commitment to develop primary care teams in dentistry. 4t is vital in an age of evidence6based medicine that this crucial area of health care benefits from evidence6based policy6making. Top of page

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