GDPs' attitudes to periodontics referrals

Key Points

• Investigates the attitudes of dentists towards the provision of periodontal treatment in general dental practice.

• Examines GDPs' attitudes towards the referral of patients to specialist periodontists.

• Explores what factors may influence referral decisions.

• Explains specific barriers to referral or drivers of referral.

• Describes how current referral pathways may be improved.

Abstract

Objective

To examine the attitudes of dental practitioners towards specialist periodontal referral in the North East of England.

Subjects and methods

Semi-structured interviews were conducted with a purposive sample of 10 practitioners. Interviews continued until data saturation occurred. The data were organised using a framework and analysed by two researchers working independently.

Results

Perceptions of periodontal disease and treatment appear to be heavily influenced by the NHS remuneration system. Treatment in general practice was limited to simple scaling and there was an apparent reluctance to treat advanced periodontitis. Such cases were commonly referred to specialists, confirming the demand for a referral service in periodontics. The perceived potential for medico-legal consequences was a strong driver of referrals. Distance to the referral centre and the perceived costs of treatment were significant barriers to referral. Dentists valued the specialist's personal reputation and clinical skills more highly than academic status. Deficiencies in communication between primary and secondary care were highlighted.

Conclusions

Increased resources are required to manage periodontal diseases within the NHS. There is a need for a periodontal referral service in the North East of England to improve accessibility to specialist care. This would appear to be most appropriately delivered by increased numbers of specialist practitioners.

Main

Attitudes regarding specialist referrals in periodontics G. Sharpe, J. A. Durham and P. M. Preshaw British Dental Journal 2007; 202: E11

Editor's summary

Published research into specialist referral processes in dentistry is somewhat limited, especially in primary care. This paper by Sharpe et al. looks at the attitudes of GDPs towards specialist periodontal referrals, in an attempt to understand more about the factors that influence referral decisions, barriers and drivers of referral and how the process can be improved. With the wide variation in referral rates and public access to specialist dental care in different parts of the UK, information such as this is vital to understand how to set about improving the system.

Perhaps unsurprisingly, the GDPs interviewed cited poor remuneration and complex fee structure as one of the factors limiting periodontal treatment in primary dental care. This research was carried out before the advent of the new dental contract in April 2006 and the paper is another stark reminder of the opportunities for improving UK dental care that were missed when it was introduced. It is unlikely that patients are now more willing to pay for complex treatment than they were at the time this research was carried out. When asked about their ideal periodontics referral service, GDPs wanted reputable specialists who were easily accessible and easy to communicate with. As the authors point out, these issues could best be addressed by providing more specialist practitioners and more resources for their training. Nearly a year into the new contract, these ideals seem as distant as ever.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 202 issue 4.

Rowena Milan, Journal Editor

Author questions and answers

Why did you undertake this research?

This research was completed as part of the principal author's specialist training in periodontics. The project was specifically intended to investigate dentists' attitudes towards specialist periodontal referral and we were particularly interested to explore the issues that may affect the decision to refer for specialist treatment. This research formed part of a Master of Science degree from Newcastle University and the principal author was awarded the British Society of Periodontology Research Award in 2005 for this work. We are very grateful to the BSP for supporting the project and we hope that readers of the BDJ will find the results of our study interesting and relevant.

What would you like to do next in this area to follow on from this work?

There have been wholesale changes in NHS dentistry since this research was carried out. Perhaps most significantly, a new contract for general dental practitioners was introduced in April 2006. This has been the subject of much discussion both within the profession and in the wider community. The implications of the new contract are huge, and it is likely that these changes will further influence attitudes regarding specialist referrals. Other developments include the introduction of Dentists with Special Interests (DwSI), after much speculation over the future direction of the dental specialities in the UK.

There are two fundamental questions that arise from the results of our work, which should be addressed in future research: is it possible to quantify the attitudes expressed in this initial study to give an indication of the strength of dentists' opinions, and have the recent changes within NHS dentistry affected referral trends in periodontics?

Comment

The introduction of a 13-week target for new patients to be seen following referral to secondary health care and the looming objective of an 18-week target for the commencement of treatment in secondary health care, mean that information about referrals is particularly timely. This paper uses semi-structured interviews of general dental practitioners in the north-east of England to investigate attitudes to specialist periodontal referral. Interviews are a useful methodology for eliciting detailed qualitative information and ensuring respondents not only understand what is being asked but are also allowed to express their views fully. This allows the researcher not only to obtain answers but also to explore the reasons for those answers. Despite the small selected sample in this study, a point of data saturation was achieved within this number of interviews. The findings of this research are also consistent with larger questionnaire-based studies in this area.¹

The results highlight a demand for specialist periodontal services to be local to referrers and patients as the distance to a specialist centre is a significant barrier to referrals. With this in mind it may be appropriate for those responsible for commissioning services to consider more practice-based specialists or out-reach clinics in order to reduce the health care inequality experienced by patients who do not live close to specialist centres. Positive feelings towards specialist providers were noted in this study, with value attributed not only to the reputation and clinical skills of specialists but also to appropriate contact and communication with referring practitioners.

The authors suggest that the NHS fee structure did not reward complex treatment, in particular periodontal treatment. Changes to the fee structure and system of payment for general practitioners introduced in April 2006 were an opportunity to address this important issue. Unfortunately, the changes introduced are unlikely to alter this situation positively and may in fact exacerbate the financial barrier to providing extensive periodontal treatment in general practice.