Skill mix and the wider healthcare agenda

The rationale for exploring skill mix in healthcare has often historically focused on its potential to provide better access to services as well as their improved efficiency and effectiveness. It incorporates the concepts of 'enhancement' or extending the scope of duties of a particular group of workers, and 'substitution' which is where one type of worker is exchanged for another.1

If we consider the wider healthcare community, examples of enhancement include the development of the role of the advanced practice nurse, the consultant nurse within the hospital sector and developing the role of healthcare assistants to take on some of the competencies traditionally undertaken by nurses.2 In terms of labour substitution, a 2005 Cochrane systematic review into the substitution of doctors by nurses in primary care found that patient health outcomes were similar for those treated by nurses and doctors with patient satisfaction slightly higher with nurse-led care.3

The proposal for a dental workforce that includes a range of dental auxiliaries to help deliver more preventive and therapeutic dentistry was first indicated in the Nuffield Foundation report into the education and training of dental auxiliaries in 1993.4However, the integration and expansion of this group, now termed dental care professionals (DCPs), in the delivery of dental services has been slow to progress.

The 'scope of practice' first published in 2009 by the GDC sought to clarify the range of clinical competencies that each individual member of the dental team could undertake.5 It has been subject to several revisions since then and the extensions to skills and duties permitted of different groups within the dental team allow for some skill mix development through both enhanced skill set and substitution (DCPs permitted to undertake more of the skillset of a dentist). In addition, in 2013, the GDC permitted 'direct access' of patients to DCPs under certain circumstances,6 with the consequence of further facilitating the potential for enhancement and substitution.

Relationship between skill mix and oral health at a population level

Recent adult dental health surveys in the UK have indicated an increase in an older population retaining an often heavily restored dentition and a reduction, at population level, in dental disease in the remaining majority of the population.7 Some have inferred that whilst the remedial operative dentistry of often increasing complexity (beyond that of the existing scope of a dental therapist) on an older population could be provided by dentists,1 DCPs could provide a large component of the required preventive care and moderate level interventions.8

This UK pattern of disease burden is mirrored in several other European countries who have been adapting the numbers of dental hygienists/therapists in their workforce to address these developing demands.9 For example, the annual entry to Dutch dental schools for therapy students has been matched to that of dental students since 2002.9 In the UK there is approximately four times the number of dentists in training as there are hygienist-therapists.10

The challenges and opportunities for clinicians in adopting skill mix

A major challenge to the adoption of greater skill mix in the provision of dental services is inherent within the makeup of the existing workforce as it stands. In 2014 there were 5,342 dental hygienists, 1,983 dental therapists, and around 40,000 registered dentists.10

The existing blend of dental professionals available in the workforce therefore has a high proportion of dentists trained to undertake the most complex procedures, with a much smaller representation of dental hygienists and therapists who are particularly well equipped to provide prevention based and moderate level interventions.

If the suppositions regarding the care we may need to provide for the different sectors of the population in the future are correct, this could produce a situation where there are many more highly skilled dentists than are strictly necessary to provide the most complex procedures (often on the older population) with a large proportion of these dentists' workload being related to providing prevention and moderate level interventions and activity, with low numbers of DCPs in the workforce (who are particularly able to provide this prevention-based care). Perversely this produces a situation where those with the lowest dental needs will be receiving their care from the most costly resource.8

So what of the future opportunities for the dentist if DCPs were to undertake more prevention and moderate level intervention activities? The volume and demand for complex procedures needing to be undertaken by dentists in the future is difficult to predict, but it is likely that what has been variously termed 'practitioners with enhanced skills' or 'level 2' practitioners,11 providing advanced care in periodontology, endodontics, oral surgery and restorative dentistry, could be a feature of NHS services provision in the future.12 In addition to these more traditional dental disciplines there is a growing demand from patients for 'newer' complex oral care treatment options such as implant-based therapies and aesthetic treatments options. Developing particular skills in traditional and/or developing fields where dentists may have a particular interest would allow them to fulfil these roles whilst increasing their appeal to future employers seeking to create their ideal skill mix and offer more choice to patients.

Challenges and opportunities for skill mix in practice

Not long after the legislative changes which allowed dental therapists to be employed in all branches of dentistry,13 a study published in the BDJ indicated that although there was a favourable attitude towards therapists, concerns were raised related to finance and patients' acceptance.1

At a practice level the business case for employing a dental therapist is heavily influenced by the funding structure. Those dental hygienists who work in the private sector where the fee for their activities can be set by the practice, can receive an adequate remuneration in relation to this fee. There is, however, limited evidence for a similar model being used to reward the hygienist-therapist for their 'substitution' restorative competencies.1 Within the current GDS arrangements hygienists and therapists do not have performer status, and therefore cannot individually generate NHS-derived income. Referral to hygienists and therapists may occur, but associate dentists may be less inclined to do this as they may not receive UDA payments associated with the referred patients' treatment.14

Interestingly, evidence from NHS pilot practices appears to suggest they see a much greater role for DCPs, with 50% of pilot practices indicating that they would want to increase the use of therapists within their skill mix,15 and this may well continue to be the experience from the current NHS prototype practices, where there appear to be significant opportunities for a large proportion of patient care to be provided by DCPs.

Concerns have also been raised regarding patients' attitudes to being referred to DCPs by the dentist to provide aspects of their treatment.1 A recent study, however, suggested patients' experiences of being treated by dental therapists are usually positive. It concluded that the elements that helped underpin this response were trust and familiarity in the dental team, including trust in the dentist delegating the care (which can reassure the patient) and through the whole team adopting an engaging, effective behaviour and communication with patients.16

Conclusion

Although at first sight broadening the skill mix within dental teams to meet the developing needs of the population appears an appealing concept, there are major challenges to be met if it is to be successful. These include adopting national policy, funding and commissioning arrangements that create an environment where change is an appealing prospect for both the dental practice and each of the individual team members who work within it.

Phillip Cannell studied dentistry at UCL and education at Cambridge. He is currently Professor and Head of Oral Health Science at the University of Essex. He has overseen the development of the largest dental hygienist programme in the UK and the one year dental hygienist to therapist BSc(Hons) degree. Last year saw the launch of the innovative clinical MSc programme designed specifically for dental hygienists which runs alongside the MSc Periodontology programme for dentists at at the University of Essex. He continues to enjoy working part time in dental practice in Leigh-on-Sea.

Phil Cannell will present a session entitled Skill mix in dentistry - A paradigm shift? How can it benefit practice in reality? on Saturday 28 May at the British Dental Conference & Exhibition 2016.

You can register for the conference online at: www.bda.org/conference. Three-day VIP conference passes are free to Extra and Expert BDA members and these free passes can be booked through the website.

British Dental Conference & Exhibition 2016

Venue: Manchester Central Convention Complex

Dates: 26-28 May 2016 www.bda.org/conference

For registration enquiries Email bda@delegate.com or call 0844 3819 769 (overseas:+44 1252 771 425)

For other enquiries visit https://www.bda.org/conference/contact-us