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Title: The delivery of primary dental care in a training environment through team working : implications for dental skill mix in England
Author: Wanyonyi, Kristina Lutomya
ISNI:       0000 0004 5369 1538
Awarding Body: King's College London (University of London)
Current Institution: King's College London (University of London)
Date of Award: 2015
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Background: In primary care dentistry, strategies to reconfigure the traditional boundaries of various professions by task sharing and role substitution have been encouraged in order to meet changing oral health needs. Training dental professionals as a team in order to encourage collaborative practice has been part of this agenda. The focus of the first part of this research is the study of patients and the care activities at the University of Portsmouth Dental Academy (UPDA) and its predecessor organisation. This is a primary care learning institution, where mid-level dental providers; hygiene-therapists (HTS) and dental nurses (DN), train together as a team with dental students on an outreach placement. UPDA was established in September 2010, as a joint venture between the University of Portsmouth’s School of Professionals Complementary to Dentistry (SPCD) and King’s College London Dental Institute (KCLDI), with the objective of improving team working. Aim: The aim of this research was to investigate the patient base, treatment activity and skill mix practice at a primary dental care team training centre prior to, and after, its establishment, and to model the potential for skill mix use in national primary dental care based on the undergraduate training experience in this centre. Methods: This research involved a case study and an operational research modelling exercise. The former was undertaken using cross-sectional electronic patient management data from UPDA, extracted in two phases: a pilot, which covered two years around the period of UPDA’s establishment [2009/10 and 2010/11], and the main data spanning a four-year period before and after UPDA was established [2008/09 and 2011/12]. The data were used to investigate the patient base, expressed treatment needs and skill mix practice using univariate, multivariate and multilevel regression analyses. An operational research model and five alternative scenarios to test the potential for skill mix use in primary care were developed, as informed by the model of care at UPDA, professional policy including scope of practice, and contemporary evidence based practice. The five scenarios included: ‘No skill mix’, ‘UPDA model nationwide’, ‘Direct access’, ‘More prevention’ and ‘Maximum delegation’. The scenario outputs were clinical time, workforce numbers and salary costs. Results: The pilot data findings from 4,343 patients suggest that there was a significant change in the patient base when the new services were initially instituted: the new patient base was older (on average 4.7 years older p=0.001); with more patients non-exempt from payment 56.8% (994) to 71.4% (1,853) (p=0.001) with lower deprivation scores; 24.5 (95%CI: 23.8, 25.2) cf to 22.3 (95%CI: 21.7, 22.8); however, there was an increased likelihood of attending in the post-expansion period for patients with a higher geographical barriers to services score, i.e. those further away from services were more likely to attend the new expanded service (0.7%; OR: 1.007 (95% CI: 1.002 to 1.012). From the main extract analysis 10,341 closed/completed treatment plans which were undertaken on 6,351 patients seen over the four-year study period showed an increase in the proportion of patients completing care plans who were in the age groups of 45-54 years and 55-64 years and adult non-exempt from NHS charges. Increasing age was associated with a higher volume of expressed treatment need in general. Logistic regression analysis showed statistically significant association p<0.05: between having received common treatments at least once in the four-year period. Payment exempt adult patients were more likely to receive all common treatments compared with the non-exempt: partial dentures (x2.6), tooth restorations (x2.1), instruction/advice (x2), tooth extraction (x1.8) and scale/polish (x1.7). The least deprived were 50% more likely to have scale and polish and 50% less likely to have tooth extractions than the most deprived. Smokers compared with non-smokers had a higher likelihood of receiving tooth restorations (57%), instruction/advice (x4), scale/polish (x1.7), tooth extractions (x2) and partial dentures (x2.6). Females patients were 20% less likely a tooth extraction or a restorations compared to male patients. Multilevel analysis indicated that the area of residence explained 7% of the variance in rate of instruction/advice, 3.8% in scale and polish and 2.8% of the variance in tooth extractions. From a sub-sample data of patients and treatments coded by provider of care n= 2,063, 55% of patients had been delegated to hygiene-therapy students at least once and 46% of coded treatments had been delegated. A significantly higher proportion of children were delegated compared with adults (85% cf 50%; p=0.001). Similarly adult smokers were delegated at a higher rate compared with non-smokers (p=0.01). The rate of delegation of different treatments also varied, with preventive treatments highly delegated (85-90%) and restorative work moderately delegated (60%). The operational research model suggested that the majority of clinical time in NHS primary care is spent on tasks that could be delegated to dental care professionals (DCP). While 45-54 year old patients received the most clinical time. Using estimated NHS clinical working patterns, the model suggested that NHS workforce numbers and salary costs to meet the dental demand in 2011/12 for each scenario were i] ‘no skill mix’ dentist only scenario would require only 81% of the dentists currently registered in England. Ii] The ‘UPDA nationwide’ scenario would lead to 29.5% of clinical time delegated to hygiene-therapists and a 357% increase in hygiene-therapists and only 57% of the dentists currently registered in England would be required and this would lead to a 19% salary cost saving cf. the ‘no skill mix’ model. iii] Minimal ‘direct access’ scenario where 70% of examinations were delegated and UPDA’s model of skill mix was practised would require 40% of registered dentists and eight times the number of hygiene-therapists’ registered; this would save 38% salary cost cf. ‘no skill mix’. iv] ‘More prevention’ i.e. increasing fluoride varnish from 13.1% to 50% and maintaining UPDAs model of skill mix, would require 4.7 times the number of hygiene-therapists’ and 57% of registered dentists. It would be a 1% salary cost saving cf. ‘no skill mix’. v] ‘Maximum delegation’ scenario with all care within hygiene-therapists’ jurisdiction delegated at 100% except restorations and radiographs (50%), showed that only 30% of registered dentists would be required and ten times the number of hygiene-therapists’ registered. This scenario could have a 52% salary cost saving cf. a ‘no skill mix’ scenario. Conclusion: The patient base in this primary care training facility represented a wide range of the societal spectrum as would be expected in general primary care practice. There was a significant change in patient base following introduction of new services and team training, to an older, more non-exempt and more geographically deprived patient population. The trend in care was associated with socio-demography and indicated increasing expressed treatment need from middle-aged patients, males and adults who would have normally had to pay for care. Over the four-year study period, routine treatments such as instruction/advice and tooth restorations, which can be undertaken by hygiene therapists, were common and patients were more likely to receive them with increasing adult age, smoking and being an adult exempt from payment. More advanced care such as tooth extraction was more common for the most deprived and smokers when compared with their counterparts. Children and adult smokers were more commonly delegated to hygiene-therapy students. Alternative scenarios based on wider predictors of expressed treatment need, changing regulations on the scope of practice and increased evidence-based practice, suggests that majority of care in primary dental practice can be delegated to hygiene-therapists and there is potential time and salary cost saving if the majority diagnostic tasks and prevention were delegated. However, this would require either more training or enhancing of roles of mid-level dental providers.
Supervisor: Gallagher, Jennifer Elizabeth ; Radford, David Robert Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available