Key points

  • Provides an understanding of the issues faced by the dental workforce in developing additional specialty-level skills.

  • Considers parallel developments in medicine.

  • Suggests improved awareness of alternative training structures can facilitate personal development.

Introduction

As the dental landscape continues to evolve via the manifestation of changes to commissioning, workforce and skillsets, it is certain that the impact of how we see dentistry and the way the public access it will be profound. It has been suggested in the last few years that the demographic of students entering dental training has changed dramatically; inevitably, this has the potential to change where and how dentists work in the future as the new generation of trainees coming through have a different mindset to their predecessors. When this is combined with modifications to how patients are managed, in the context of how the new commissioning guides suggest patient-flow might be affected, it is obvious that big changes are afoot.

In recognising the changing tide, it is prudent to consider how the profession might adapt to best accommodate themselves in times of uncertainty. This includes how we facilitate further training and also how specialists across primary and secondary care manage themselves in the workplace to best position themselves and their colleagues to accommodate their lifestyle and career needs.

Inevitably, the future workforce will have different requirements and now is the time to decide how to meet its needs. Additionally, specialist training numbers and services delivered by specialists and consultants (level 3 services) will need to reflect the needs of the population and the changing demographics of local areas. With this concept in mind, one option that currently exists within training frameworks stands out as one potential solution. Despite the paucity in data available reflecting different areas of workforce across in dentistry, integration and adaptation of less-than-full-time training (LTFT) are explored here, as a more common means of training might resolve some of the uncertainties that exist around the developing workforce.

Health Education England dental workforce group

Health Education England (HEE) has established a 'dental workforce group' which aims to collect data on the need for speciality training posts in the 13 recognised dental specialties to create a dental workforce strategy to meet population needs.1 The group recently made recommendations which included: '[we] need to liberate the workforce to facilitate the necessary developments and continue to shape it over time to serve population needs',2 and that 'this requires courage, creativity and collaboration to move our workforce from good to great'.

Demand for the development of specialists will also be determined by the needs of the local population and advice around development should be sought from dental public health groups as well as commissioners and providers of service. The commissioning guides which continued to evolve in 2015 are likely to 'result in new models of dental care delivery over time; and the need for much closer working between HEE and NHS England at both national and LETB level to ensure both current and future dental workforce development needs can be met'.1

Current specialist trainees

When considering the speciality workforce, we must consider how speciality training exists in its current context; this article does not aim to replicate articles that have previously been produced but only purvey an overview.3 There are currently 13 routes onto specialist lists that are recognised by the General Dental Council (GDC).4 The number of trainees that currently exist in training varies between specialties (Fig. 1), as well as geographically (Fig. 2).5,6 The routes to speciality status are also varied and are explicitly detailed by the Committee of Postgraduate Dental Deans and Directors (COPDEND).7

Fig. 1
figure 1

Dentists in specialist training posts at 31 December 201343

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Fig. 2
figure 2

Speciality training posts at 31 December 2013, by HEE area in UK6

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Beyond speciality training, there is also much work and debate around level 2 dentists and their role in intermediate services. Ibbetson remarked that, in the void between primary and secondary dental care, where the intermediate services have been evolving, is a distinct lack of development surrounding this type of competency that is not addressed by specialists given a potential lack of funding within the health service.4 He suggests that this lack of funding and development of the middle tier has given rise to a stagnation of any progress that may encourage more dentists to progress with their own careers and skills. Responses to this opinion piece highlighted that, in the case of oral surgery, the need for specialists and consultants is perhaps dictated by the commissioning guidelines in their call for dispensation of services to appropriately-trained clinicians. The subsequent development of services such as oral surgery has seen the evolution of accreditation criteria8 for those in such services, but has drawn equal criticism regarding the effects of such guidelines and in consideration of other aspects of workforce development.9

Less-than-full-time training (LTFT)

What is LTFT training?

LTFT training is defined by European Law (EC directive 93/16/EEC) as being part-time training that involves a limitation in participation in medical or dental activities, but trainees must usually work at least half the time of a full-time trainee. The Dental Gold Guide 2016 outlines the parameters in which an individual can apply for LTFT training.10 All trainees are entitled to apply for LTFT training, provided they meet eligibility criteria which include illness, disability, caring responsibilities, and opportunities for personal and professional development. The guide states only one additional reason why LTFT training may be considered: 'if the supply/demand ratio of potential trainees is unfavourable then HEE, NES, NIMDTA or Wales Deanery may consider the development of part-time training posts in specific specialties'. It is within this context that it may be worth considering how training the workforce might be adapted to best fit changes in the profession. LTFT is traditionally a facilitator that can help dental professionals to stay in the profession who otherwise may have been lost from the workforce if they are unable to commit full-time to a post for a variety of reasons.

Identifying data pertaining to dentistry is challenging with respect to how many LTFT trainees are currently in post and the historical trends. However, it seems there are only few when discussing with educators; full consideration of this data would aid workforce planning teams to evaluate the projected need for specialists in the future more accurately alongside the changing expectations of those undergoing training.

Here we outline possible reasons why some dental professionals may want to consider LTFT to become level 3 practitioners and why considering this in the development of future posts may be of benefit to the profession.

Comparisons to medicine

NHS medical and dental staff are bound by the same terms and conditions of service.11 The General Medical Council's 'National training survey 2014' shows that 11.3% of doctors were in LTFT training, up from 6.1% in 2011.12 The 'Shape of training' review recommended that future training models should be more flexible, to achieve a better work-life balance, pursue outside interests or research, teaching, or leadership responsibilities.13 This was then championed by the BMA, GMC,14 medical Royal Colleges and other national organisations to build a diverse and sustainable workforce. A study by Hunningher et al. found that LTFT anaesthetic trainees (95.6%) were as successful as full-time trainees (95.7%) at obtaining consultant jobs.15 The BMA currently offers guidance,16 as well as detailed figures,17 for trainees considering and currently in LTFT placements.

There is currently a lack of evidence showing the training outcomes of LTFT dental speciality trainees: If dental trainees are bound by the same terms and conditions, it could be argued that we should be supporting more opportunities based on existing evidence.18

Lifestyle and morale

Working LTFT has many benefits, including reducing exhaustion, preventing burnout and achieving a better work-life balance, which can in turn improve enthusiasm for work. Several studies have reported that young trainees often struggle with morale19 and one of the many reasons for choosing a career within dentistry is typically an association with quality of life within the profession as well as flexibility in working life.20,21 Furthermore, feeling a sense of value as well as being able to maintain personal values and aspirations as part of career progression appears to be important.22,23 Although underreported, there are studies highlighting how burnout within the profession is not an unknown ailment affiliated with several career stresses;24,25 some investigations have shown up to 75% of those in training (depending on speciality) may suffer from burnout.26 The British Dental Association has highlighted that there is strong evidence that working under the current NHS contract is associated with stress and burnout among dentists.27

Gender equality

It has been determined that healthcare professionals are increasingly seeking flexible solutions within their working lives to enable them to achieve their potential in their careers but also to be able to properly support their families.

It is clearly apparent that females are more likely than males to take time off work and subsequently work part-time following the birth of a child,28 and this is also apparent based on figures from the BMA17 The number of women working in NHS dentistry is steadily rising. In 2014/15, there was a 3.1% increase in the number of female dentists from 2013/14 in England.29 This equates to a 44.2% increase from 2006/07. With the changing demographics of an increase in female dentists coupled with the fact they are currently more likely to work part-time, there needs to be an overhaul in future workforce planning. However, the introduction of shared parental leave in 2015 may stimulate cultural changes to fade out typical gender roles, which may start to erode the current demographics.30

Either way, there will be an increasing need for flexibility in training for dentists wishing to progress their careers to provide a level 3 service. If the recently published commissioning guides suggest more level 3 services are required than are currently in the dental market, consideration will need to be given to flexible working and training in order to meet the workforce requirements for the future of the dental profession. Additionally, it could be argued that, by limiting the provision of LTFT, it could be deemed as gender discrimination against females who wish to work or train part-time. Newton suggested 'if we wish to retain the rich diversity and quality of dental practitioners that we now have then we may need to think about structuring employment to make it easier for those who choose to work part-time'.31

Finance

Some dental speciality training posts are accompanied with high course fees, including orthodontics and mono-speciality courses for endodontics, periodontics and prosthodontics. During the training period, a stipend may or may not be available. Those courses where one is available, the pay scale is usually that for NHS speciality registrars. Those dental professionals who do not have the financial means to accept a limited income, or no income at all, may seek to train LTFT to supplement their income by working elsewhere for the remainder of the week, for example in general dental practice. Not considering LTFT training for level 3 services will create inequalities and inequities within the dental workforce. This can be viewed as the process being anti-competitive due to the constraints on the learning and development of the dental workforce and act as a barrier for well able and qualified potential candidates from applying for speciality training posts.

Disability and carers

Some dental professionals may have a disability or medical condition of some form, which may prevent them from working full-time in a post. The BMA estimate that 2.5% of LTFT training posts in medicine are owing to a disability.32 Not allowing the consideration of LTFT posts to gain specialist skills may potentially be seen as discrimination. Additionally, some professionals may have responsibilities as carers for close family. By having the option of LTFT, the dental workforce can take advantage of highly-skilled potential candidates who otherwise would not be able to progress in their careers.

The 'portfolio' career

As dentistry becomes more competitive in terms of the service we provide and tendering of contracts, there seems to be an aspiration towards the development of the 'portfolio career.' Portfolio careers offer more flexibility, variety, autonomy, freedom and a better work-life balance, as well as risk tolerance. It enables an individual to use multiple skill sets and allows them to follow multiple passions for personal growth and fulfilment. Although a new concept to some in terms of the title, many are already inadvertently pursuing such careers through the sheer diversity of their working week (for example, combining clinical work with teaching, academia, supporting other business interests etc). Furthermore, a study of academic clinical fellows (academic speciality trainees) showed that most would not pursue isolated research/academic careers because of competition around securing grants and internal job pressures.33 These multifaceted elements have been highlighted in dental circles too.34 Due to the lack of job security in today's workplace, it would be wise to consider multiple facets, especially within the dental profession.

There are currently few incentives to incorporate a career in academia with clinical practice in dentistry. The development of NIHR-funded academic clinical fellowship (ACF) posts have helped to alleviate this in recent years.35 However, limiting the availability of LTFT posts may further discourage dentists with an interest in academia from pursuing this alongside their specialist training.

It has never been more critical to gain training in management and leadership within dentistry, in order to keep abreast of the ever-changing health care system and to prepare specialists for roles in teaching, education and department management. To accommodate this requirement, LTFT can assist in professional development and gaining competency in this area.

With the changing mindset of trainees and practitioners hinting towards a more varied and diverse career, it is essential that training reflects this change in behaviour so as not to upset health services and workforce balance:15 this is also crucial if the public health sector wants to retain trainees in the service as well as support a more formalised structure to empower training in this way.

Will we be moving towards a model where specialists only work part-time delivering level 3 services and spend the remainder of their working week working in specialist primary care? If more specialists are needed in line with the requirements in the commissioning guides and more are working part-time in NHS, this might create more variety in the workforce resulting in a wider array of competencies and ways of thinking, which could bring an increased innovative and creative mix to the profession.

Impact on the specialist workforce

Consideration should be given to the likelihood of LTFT trainees taking up LTFT consultant posts upon completion of training. Hunningher et al.15 found that only 3.4% of LTFT anaesthetic trainees took up LTFT consultant posts, compared to 1.75% full-time trainees36 taking up LTFT consultant posts. Seemingly, this has only a small impact on whole time equivalent consultant numbers.

If there are an increasing number of individuals who wish to work in consultant posts as LTFT, there may need to be a shift in the consultant workforce structure and how we delegate working time equivalents. This could be deemed advantageous by having more consultants in the workforce who may bring varied ideas and innovations to further benefit patients and the workforce as a whole. The concept of job sharing is not new,37 however the influence on job role and speciality has previously been seen to affect who is more likely to take on less-than-full-time job roles.38 Irrespective of this, work-life balance has been seen to clearly influence early career choices in medical trainees.39,40

Challenges for LTFT

A direct effect of LTFT is that take-home pay will be reduced on a pro-rata basis and pay progression will take longer. Conversely, the opportunity to support oneself in general practice as a dentist provides an opportunity to supplement income (in a way not often available to those in medicine) and for certain specialties, such as dental public health, this may provide an opportunity to engage with clinical activity too, especially as completion of training is delayed.

Those working in LTFT posts have reported they feel they are taken less seriously than their full-time colleagues.41 It can also be difficult to attend training sessions if they fall on a non-working day of the week. Demonstrating commitment through working longer hours may also prove more challenging. The lack of continuity may be a major drawback of working LTFT, not only in terms of patient care, but also in terms of learning and acquiring a breadth of experience.

Funding for LTFT posts may prove challenging for NHS trusts and education commissioners, that is, HEE. Individuals may work in a 'job share' or a 'slot share' with other colleagues wishing to work or train LTFT, or may be a supernumerary, finance-permitting, and might require pilot-type programmes to support their validity.

Other challenges may include:

  • Training will take longer to complete, meaning a longer wait until more specialists are in circulation

  • It may take longer to become integrated with the team

  • Training opportunities may be missed or limited

  • Less continuity with patients (workload/speciality specific).

To prevent these challenges from occurring, it is vital that professionals wishing to train LTFT for level 3 service provision ensure they fulfil all the competencies required to the minimum standards expected of the GDC for completion of specialist training.42

Conclusion

The case for LTFT appears to remain strong, however the model of training delivery may need to evolve to maintain pace with the changing service delivery model in the NHS. The range of training opportunities may also need to be broadened to meet the wider requirements of the health system. Flexibility within LTFT seems to be a valid consideration and should be factored in to support portfolio careers and to optimise the opportunities open to trainees. The model of LTFT training managed by HEE can appear inconsistent when applied to dentistry and does not necessarily recognise the specific needs of dentistry. The dental workforce needs are likely to change again and, as such, LTFT training needs to be developed to meet these needs.