Endodontics at the coal face

Key Points

In brief

• General dental practitioners find it difficult to provide quality molar endodontics on the National Health Service.

• Bringing performance into line with good practice guidelines needs to be underpinned by an understanding of barriers to compliance.

• Endodontic practice is affected by a complex web of influences, including time-fee pressures and the quality of basic and post-basic education. General dental practitioners adopt rational strategies in managing the constraints placed upon them.

• Simply raising endodontic fees may not be the answer. A system which rewards quality rather than volume may be appropriate, but effective policing of standards would be required. The system would also have to balance efficiency with effectiveness within a limited healthcare budget.

• The quality of basic and post-basic education in endodontics should be reviewed, with considerable flexibility of approach, and active responsiveness to the needs of trainees at every level.

Abstract

Aims Concerns have been expressed about the technical quality of NHS endodontic treatment. Bringing performance into line with guidelines for good practice needs to be underpinned by an understanding of barriers to compliance. To this end, our research involved an exploratory investigation of the factors influencing the behaviour of general dental practitioners in their practice of endodontics.

Materials and methods Subjects: 12 dental practitioners, representative of varying levels of professional experience and status, and of compliance with good practice guidelines. Data collection: In-depth interviews, following a topic guide. Analysis Identification, abstraction and charting of major themes.

Findings Informants' responses suggested that general dental practitioners' endodontic practice is influenced by a complex web of factors. A key barrier to high quality treatment is the NHS remuneration scheme. Undergraduate and postgraduate education and training are also highly influential on practice. Dentists reported employing a range of strategies to manage the time-cost tensions imposed by the remuneration system. Perceived deficiencies in the content and delivery of postgraduate training were highlighted by our informants.

Conclusions There was a perception among our informants that the NHS fee structure needs to be revised. Their views suggest that a system which rewards quality rather than volume may be more appropriate, but, we believe, such a system would need to take into account efficiency as well as effectiveness. Modification of the current system of postgraduate training in endodontics is also indicated by the views expressed in the interviews. From the diversity of views and from a critical review of the literature, we conclude that flexibility is the key note in changing practice, with no single strategy likely to be universally appropriate.

Main

Barriers to improving endodontic care: the views of NHS practitioners McColl E., Smith M., Whitworth J., Seccombe G. and Steele J. Br Dent J 1999; 186: 564–568

Comment

Before moving into an 'academic' career, I spent 15 years in general dental practice, working almost totally under the NHS. I have to admit that one of the main reasons for leaving general practice was a reluctance to continue compromising my standards for financial reasons any longer. However, the fact that I had been sued by a patient for doing exactly that was also part of the equation. I can therefore empathise deeply with practitioners who have willingly opened their hearts in this excellent survey.

I can also empathise with the academics and specialist practitioners who are faced daily with difficulty or even impossible retreatments of cases where the attempted endodontic treatment does not comply in any way with accepted clinical guidelines.

Finally, almost every professional dentist must empathise with the poor patient, stuck as they are in the middle of this battle. They pay their taxes, but are told that the fees allocated by the Dental Rates Study Group do not allow acceptable treatment. We read here that some dentists merely extract the teeth and do not offer endodontics to these patients. Some at least accept the patient's rights to treatment, and refer to a colleague or the long waiting list of a hospital consultant. And some, perhaps may, provide inadequate treatment.

Where I cannot empathise is with the leaders of our profession who have allowed this situation to arise. I actually found this paper exceedingly depressing. When I graduated it was probably the proudest day of my life. I had joined a profession. I had taken the Hypocratic Oath. I would do the best for my patients, with no thought for personal considerations. But the real world of dentistry is different. A student interviewed on a television documentary about dental education suggested that, if I really wanted to care for people, I should have joined the Salvation Army! A dentist in this survey claims to feel no need to attend postgraduate courses as 'my year as a vocational trainee was enough for me'.

I have not provided a resumée of this paper as I think every dentist must read it in its entirety. I hope this paper, and subsequent publications from the same authors, will promote wide debate. I hope it will be used as ammunition by those who wish to improve endodontic treatment as evidence by the General Dental Council who have advised the British Endodontic Society (BES) that they cannot take action on standards without concrete evidence, and as guidance by those with responsibility for organising dental education, both undergraduate and postgraduate.