It is common-place in many healthcare settings, but not in dentistry. The reluctance to embrace skill mix and utilise its full potential is only now being explored. As research and health needs inform a shift from invasive, operative treatment to prevention and maintenance, naturally the way we provide care as a workforce will need to adapt too.

Phillip Cannell and Emma Pacey teach the next generation who will be embracing skill mix as it inevitably becomes the foundation of successful practice. News editor David Westgarth sat down with Phillip and Emma to discuss the value they place on skill mix in training and what the future may look like.

Phillip Cannell is Professor and Subject Lead for Oral Health Science at the University of Essex. Emma Pacey is a Lecturer in Oral Health Sciences at the University of Essex.

Simple question to start off with: why has it taken so long to get to this point?

EP Historically the dental profession has been led by the dentist; they have been the sole authority in practice and everything filtered from there. Change takes time, both to come around and to be accepted. It was only in 2002 that dental therapists entered general dental practice. Before then they were confined to hospital and community-based settings, which limited their access to the dental team and the public.

PC We've been doing some research and we think there are around 2,500 therapists, 6,500 hygienists and 41,000 dentists, so you can see one component of the problem. A lot of dentists – with the exception of nursing support – are often working with only limited skill mix in practice. The Department of Health (DH) are considering how to best integrate skill mix, and it's also something the Centre for Workforce Intelligence (CfWI) have been looking into. As Emma says dentistry is deep rooted in its traditional ways, and the benefit of outside parties looking in and making recommendations can only benefit our profession, but change will take time.

You've just mentioned that the sheer number of dentists outweighs hygienists and therapists. Why is there a greater need for integration of skill mix in practice?

EP It's about meeting the needs of the public in an economically sustainable way. Patients have previously been treated almost exclusively by dentists; however, remuneration of a workforce providing NHS subsidised care at this skill level just isn't viable anymore. Additionally, the burden of dental disease is less; people don't need as much operative treatment as they once did. There will always be a need for complex dentistry, but with the profession geared towards prevention, the focus of the workforce, and workforce planning, needs to change accordingly. There is substantial scope for dental hygienists and therapists to make a difference here.

PC I don't think it's stretching the imagination to say that hygienists have at least as good and probably often a better understanding and knowledge of periodontal care than an undergraduate dentist, primarily because this accounts for a very significant area within their training.

Right now that expertise fits the needs of the population.

What do you think of the childhood tooth decay statistics? If skill mix was already bedded down and the norm in practice would we see the same figures?

EP The statistics represent an unmet oral health need in society, which is unacceptable. From a public health point of view the dental team has little impact on levels of disease. For children it's about the environment in which they grow up. However, the profession, with its specialist knowledge, is best placed as the driver for change, and this is necessary at every level. Primary dental care provision is important, but more so are wider reaching strategies; oral healthcare at every level can be facilitated by hygienists.

PC What interests me the most is that not every person has to see a dentist for the dental health of the population to improve. There is a large proportion of the population not seeking routine dental care for one reason or another. There will always be the inevitable section who attends when they need to, and this pretty much remains a constant. There are so many more opportunities to help achieve dental health in the population than simply attempting to treat disease away or through preventing disease purely through the practice setting.

EP That's so true. You only have to look at the Designed to Smile initiative in Wales and Childsmile in Scotland – delivered by a multidisciplinary team – to see the difference population level intervention can have. Contact at early in life embeds habits and shapes expectations from a young age, which pays dividends later in life.

So from an economic point of view it would pay to have more hygienists and therapists?

EP Most definitely. And not just hygienists and therapists, but extended duties nurses too, working with allied health professionals in multidisciplinary settings; clinical, educational and residential in an integrated care model. The datasets from Childsmile demonstrate significant reductions in disease burden in 10 years, which has significant implications for health economics. With the financial investment similar year on year, the reduction in general anaesthetics alone saves thousands.

PC That's the problem though. England doesn't have the same burden of disease. We know in order to make a difference we can't just treat the needy. We have to be able to care for everyone, and that includes those who fit a maximum recall period. We need to harness the talents of the whole team if we are going to get anywhere near to achieving this. As a DCP it's an incredibly exciting time to be in the profession.

Are you seeing that reflected in the students you teach?

PC Very much so, yes. Hygienists and therapists sometimes report that they are unsure of who to turn to if they have concerns perhaps with a patient's ongoing care, within a practice environment which may arise through a feeling of isolation within practice. Many of our recent graduates feel because of their immersion in practice essentially right from the word go there has been little anxiety in this area when following graduation they move into practice, as their training has helped them understand the full contribution their role can make within the skill mix of a practice. Likewise if they are in a hospital environment.

Direct access (DA) has also opened up the realms of possibility for a hygienist and therapist, through acknowledging their autonomy to make high level decisions in the best interest of the patient.

Yes there is more control in the educational setting where students are protected to a certain degree, but we pride ourselves on developing in our students the intuition and independence to stand on their own two feet in the real world of practice because these skills are crucial for the future practice environment

EP I can only echo Phil's thoughts. The structure of hygiene and therapy initial training programmes means students become knowledgeable very quickly in their area. They are training at the same level within their scope of practice as BDS students. For example, we think it is entirely appropriate that hygienists should be well versed in the indications for surgery and the different approaches, particularly in light of DA.

You mention direct access quite a lot. What implications does it have for training institutions?

PC It has massive implications. One minute it wasn't there the next it was. Prior to DA there was the necessity for dental hygienists and therapists to train to practise under the guidance of a dentist. Now we are moving away from them always working under the supervision of a dentist to becoming independent and self-competent within the GDC scope of practice. So we have the challenge to design programmes that also develop the skills required for autonomy and independence.

EP The GDC terms it being a 'safe beginner'; this is what we're aiming for at sign off. It's wholly appropriate, that with the necessary training hygienists and therapists work under DA, as do their allied health professional counterparts. However, this has implications for the level at which we teach and the responsibility of registrants, as well as clinical environments. Dental hygienists often practise in an isolated working environment and in some situations DA may have the potential to exacerbate this.

What advice would you give to an undergraduate/post-graduate looking to expand their repertoire?

EP There are many directions registrants can take post initial training; however, these are not as well defined, nor developed for dental hygienists and therapists. To a certain extent, one has to carve one's own career pathway, but this is beginning to shift. We now have a ground breaking MSc programme at Essex that allows dental hygienists to access a masters level programme (traditionally this required a BSc or BA). Although some hygienists and therapists have a BSc, many have level five qualifications such as diplomas or foundation degrees. The course allows a jump from level five to level seven training, which is totally unique. Additionally, it fosters a skill mix approach as dental hygienists progress alongside dentists training to be periodontists.

PC The job market is extremely competitive. Just in the last 5 years we have witnessed a significant change in the employment destinations of our graduates. This has partly occurred through supply and demand. Five years ago you could have graduated and found yourself with a choice of one or two private practices to join. Now we are seeing more and more graduates take employment in a range of practices both NHS and private and be quite discerning about the environment in which they know they can make their full contribution. But they also realise they need to expand their skills to improve their employability. Hygienists and therapists will be a crucial part of the team in years to come judging by the needs of the public. There is a very well defined career pathway for a GDP, historically this has been more rigid and limited for a DCP, but this needs to change and it is changing. You can forge your own path provided you have the right attitude.