Alternative scenarios: harnessing mid-level providers and evidence-based practice in primary dental care in England through operational research
Tóm tắt
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. 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. 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. 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”. 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.
Tài liệu tham khảo
Department of Health. Liberating the NHS: developing the healthcare workforce from design to delivery. Department of Health; 2012.
General Dental Council. The scope of practice. London: General Dental Council; 2013.
Alliance GHW. Mid-level health workers for delivery of essential health services a global systematic review and country experience. Geneva: World Health Organization; 2012.
Dovlo D. Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review. Hum Resour Health. 2004;2:7.
Department of Health and British Association for the Study of Community Dentistry. Delivering better oral health: an evidence-based toolkit for prevention. 1st ed. London: Department of Health and British Association for the Study of Community Dentistry; 2007.
Department of Health, British Association for the Study of Community Dentistry. Delivering better oral health: an evidence-based toolkit for prevention. 2nd ed. London: Department of Health and British Association for the Study of Community Dentistry; 2009.
Public Health England, Department of Health, Public Health England, Department of Health, British Association for the Study of Community Dentistry. Delivering better oral health: an evidence-based toolkit for prevention. 3rd ed. London: Department of Health; 2014.
Steele J, O’Sullivan I. Adult dental health survey. London: (Health Do ed) The Health and Social Care Information Centre; 2011.
Office of National Statistics, Health and Social Care Information Centre. Child dental health survey 2013, Health and Social Care Information Centre. 2015.
General Dental Council. Guidance on direct access. London: General Dental Council; 2013.
Turner S, Tripathee S, Macgillivray S. Direct access to DCPs: what are the potential risks and benefits? Br Dent J. 2013;215:577–82.
Macey R, Glenny A, Walsh T, Tickle M, Worthington H, Ashley J, et al. The efficacy of screening for common dental diseases by hygiene-therapists: a diagnostic test accuracy study. J Dent Res. 2015;94:70S.
Harris RV, Sun N. Translation of remuneration arrangements into incentives to delegate to English dental therapists. Health Policy. 2012;104:253–9.
Brocklehurst P, Tickle M. Is skill mix profitable in the NHS dental contract? Br Dent J. 2011;210:303–8.
Harris RV, Sun N. Dental practitioner concepts of efficiency related to the use of dental therapists. Community Dent Oral Epidemiol. 2012;40:247–56.
Brocklehurst P, Birch S, McDonald R, Tickle M. Determining the optimal model for role-substitution in NHS dental services in the United Kingdom. BMC Oral Health. 2013;13:46.
Dyer TA, Humphris G, Robinson PG. Public awareness and social acceptability of dental therapists. Br Dent J. 2010;208:16–7.
Dyer TA, Owens J, Robinson PG. The acceptability of care delegation in skill-mix: the salience of trust. Health Policy. 2014;117:170.
Dyer TA, Robinson PG. Exploring the social acceptability of skill-mix in dentistry. Int Dent J. 2008;58:173–80.
Sun N, Burnside G, Harris RV. Patient satisfaction with care by dental therapists. Br Dent J. 2010;208:9.
Dyer TA, Brocklehurst P, Glenny AM, Davies L, Tickle M, Issac A, et al. Dental auxiliaries for dental care traditionally provided by dentists. Cochrane Database Syst Rev. 2014;8, CD010076.
Garrett M. Health futures handbook. Geneva: World Health Organization; 1999.
Gallagher J, Kleinman E, Harper P. Modelling workforce skill-mix: how can dental professionals meet the needs and demands of older people in England? Br Dent J. 2010;208:116–7.
Harper P, Kleinman E, Gallagher JE, Knight V. Cost-effective workforce planning: optimisating the dental team skill-mix for England. J Enterp Inf Manag. 2013;26:91–108.
Centre for Workforce Intelligence. Securing the future workforce supply: dental care professionals stocktake. London; 2014.
World Health Organization, Global Fund. Guide to operational research in programs supported by the global fund. Geneva; 2009.
Wanyonyi KL, Radford DR, Gallagher JE. The relationship between access to and use of dental services following expansion of a primary care service to embrace dental team training. Public Health. 2013;127:1028–33.
Wanyonyi K, Radford D, Gallagher J. Dental skill mix: a cross-sectional analysis of delegation practices between dental and dental hygiene-therapy students involved in team training in the South of England. Hum Resour Health. 2014;12:65.
Bearne A, Kravitz A. The 1999 BDA Heathrow Timings inquiry. Br Dent J. 2000;188:189–94.
Robinson PG, Patrick A, Newton T. Modelling the dental workforce supply in England. Sheffield: University of Sheffield; 2011.
Wanyonyi KL, Radford DR, Gallagher JE. Dental skill mix: a cross-sectional analysis of delegation practices between dental and dental hygiene-therapy students involved in team training in the South of England. Hum Resource Health. 2014;12:1478–4491.
Health and Social Care Information Centre. NHS dental statistics for England: 2011/12. London: Health and Social Care Information Centre; 2012.
National Careers Service. Salary ranges: dentists and hygiene therapists. 2013.
Sun N, Harris RV. Models of practice organisation using dental therapists: English case studies. Br Dent J. 2011;211:6.
Harris R, Burnside G. The role of dental therapists working in four personal dental service pilots: type of patients seen, work undertaken and cost-effectiveness within the context of the dental practice. Br Dent J. 2004;197:491–6.
Foundation N. Education and training of personnel auxiliary to dentistry. London: Nuffield Foundation; 1993.
Swedberg Y, Malmqvist J, Johnsson T. A method for dental care activities time study using observer monitored counting of frequencies. Swed Dent J. 1993;17:155–63.
Wang NJ. Variation in clinical time spent by dentist and dental hygienist in child dental-care. Acta Odontol Scand. 1994;52:280–9.
Swedberg Y. The use of time study results in a system model for presenting dental care outcome. Swed Dent J. 1995;19:161–71.
Evans C, Chestnutt IG, Chadwick BL. The potential for delegation of clinical care in general dental practice. Br Dent J. 2007;203:695–9.
Leyssen W, Clark RKF, Gallagher JE, Radford DR. Developing professional status: an investigation into the working patterns, working relationships and vision for the future of UK clinical dental technicians. Br Dent J. 2013;214, E3.
Fitzpatrick J. Oral health care needs of dependent older people: responsibilities of nurses and care staff. J Adv Nurs. 2000;32:1325–32.
Locker D, Frosina C, Murray H, Wiebe D, Wiebe P. Identifying children with dental care needs: evaluation of a targeted school-based dental screening program. J Public Health Dent. 2004;64:63–70.
Milsom KM, Jones C, Kearney-Mitchell P, Tickle M. A comparative needs assessment of the dental health of adults attending dental access centres and general dental practices in Halton & St Helens and Warrington PCTs 2007. Br Dent J. 2009;206:257–61.
Steele J. A review of NHS Dental Services in England: an independent review. London: Department of Health; 2009.
Gallagher JE, Wilson NHF. The future dental workforce? Br Dent J. 2009;206:195–9.
Watt RG, Williams DM, Sheiham A. The role of the dental team in promoting health equity. Br Dent J. 2014;216:11–4.
Yee R, Sheiham A. The burden of restorative dental treatment for children in Third World countries. Int Dent J. 2002;52:1–9.
General Dental Council. Registrants reports. London; 2015.
Richardson MSC. Identifying, evaluating and implementing cost-effective skill mix. J Nurs Manag. 1999;7:265–70.
Gibbons D, Corrigan M, Newton JT. The working practices and job satisfaction of dental therapists: findings of a national survey. Br Dent J. 2000;189:435–8.
NHS Education for Scotland. Dental workforce report 2014. Edinburgh, Scotland: NHS Education for Scotland; 2014. p. 2014.
Scarrott DM. The economic case for delegation in dentistry. Br Dent J. 1973;134:23–4.
Sanglard-Oliveira C, Werneck MA, Lucas S, Abreu MHNG. Exploring professionalization among Brazilian oral health technicians. Hum Resour Health. 2012;10:5.
Freidson E. Professionalism: the third logic on the practice of knowledge. Chicago: The University of Chicago Press; 2001.
Dyer TA, Owens J, Robinson PG. What matters to patients when their care is delegated to dental therapists? Br Dent J. 2013;214:275.
Wake C. Direct access for dental therapists and hygienists--when do we refer? Prim Dent Care. 2014;3:77–9.
Bullock A, Firmstone V. A professional challenge: the development of skill-mix in UK primary care dentistry. Health Serv Manag Res. 2011;24:190–4.
Pinder R, Petchey R, Shaw S, Carter Y. What’s in a care pathway? Towards a cultural cartography of the new NHS. Sociol Health Illn. 2005;27:759–79.
McKendrick A. The economics of caries prevention by dental hygienists. Public Health. 1971;85:219–27.
Wang NJ. Use of dental hygienists and returns to scale in child dental care in Norway. Community Dent Oral Epidemiol. 1994;22:409–14.
Beazoglou TJ, Lazar VF, Guay AH, Heffley DR, Bailit HL. Dental therapists in general dental practices: an economic evaluation. J Dent Educ. 2012;76:1082–91.
Linna M, Nordblad A, Koivu M. Technical and cost efficiency of oral health care provision in Finnish health centres. Soc Sci Med. 2003;56:343–53.
Yin RK. Case study research: design and methods. London: Sage; 2009.