Summary of: What matters to patients when their care is delegated to dental therapists?

Key Points

• Reports positive views and experiences of care provided by dental therapists.

• Suggests that trust is built on the communication skills and attitude of the dental team (affective behaviour) and continuity of care.

• Reports negative experiences of dental therapist care in cases where communication was poor and continuity of care was lacking.

Abstract

Aim To explore the experiences of adult patients and parents of child patients when their oral healthcare is delegated to dental therapists.

Method Narrative study using semi-structured in-depth interviews of a purposive sample of patients (n = 15) and parents of child patients (n = 3) who have been treated by therapists.

Results Overall, participants reported positive experiences of treatment provided by therapists. Two main themes emerged from the data. The first; perceptions of the nature of dental services appeared related to the second; trust and familiarity in the dental team. Perceptions of the nature of dental services ranged from viewing dentistry as a public service to that of a private service, consistent with a more consumerist stance. Within this theme, three dimensions were identified: rationale for skill-mix; team hierarchy and importance of choice and cost. Consumerist perspectives saw cost reduction, rather than increasing access, as the rationale for skill-mix. Such perspectives tended to focus on hierarchy and a rights-based approach, envisaging dentists as the head of the team and emphasising their right to choose a clinician. Trust in and familiarity with the dental team appeared critical for therapists to be acceptable. Two dimensions were important in developing trust: affective behaviour and communication and continuity of care. Two further dimensions were identified in this theme: experience over qualification and awareness of therapists. Where trust and familiarity existed, participants emphasised the importance of their experiences of care over the qualifications of the providing clinician. Equally, trust in the dentist delegating care appeared to reassure participants, despite awareness of the role of therapists and their training being universally low.

Conclusion Regardless of perspective, views and experiences of treatment provided by therapists were positive. However, trust in and familiarity with the dental team appeared critical. Trust was apparently founded on dental teams' affective behaviour, communication skills and continuity of care. There are implications for skill-mix where staff turnover is high, as this is likely to compromise familiarity, continuity of care and ultimately trust.

Main

T. A. Dyer British Dental Journal 2013; 214: E17

Author questions and answers

1. Why did you undertake this research?

The recent debate in the UK about direct access to dental therapists identified that little is known about public and patient views of having their care delegated to them. Knowing the answers to these questions is essential in any debate about the impact of increased use of skill-mix on the quality of UK dentistry.

Although high levels of satisfaction have been reported by therapists' patients, questionnaire surveys are too inflexible to adequately identify reasons for this and to identify dissatisfaction. This study allowed us to talk to adults and parents of children who had been treated by therapists and enabled us to explore their views and experiences.

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

Two aspects of these findings require consideration. Firstly, the overwhelmingly positive views and experiences reported here are largely derived from a small number of practices working to a NHS contract, which arguably does not facilitate the use of skill-mix. Secondly, where dissatisfaction was reported communication appeared poor and staff turnover was high. A study designed to identify dissatisfaction and the reasons for it would be beneficial. In addition a larger study of the acceptability of care provided by therapists would be useful, where patient satisfaction is compared in practices employing therapists and those that do not. Ideally this should be undertaken in practices working under the prospective new NHS contract arrangements.

Commentary 1

Two broad dimensions emerged from the data collected in this study: (i) the nature of dental services and (ii) trust and familiarity. The latter is related to the powerful influence of communication and relationship factors in predicting satisfaction with healthcare.¹ The former theme allows us insight into the way in which a consumerist perspective modifies the nature of the healthcare relationship. Currently dentistry in the UK occupies an interesting and fairly unique position in our healthcare system in that patients are required to make co-payments on receipt of care. Unlike a pharmacy where patients pay for their prescriptions, in dentistry the supplier is also the one making the prescription of care. Thus the interaction has several features of a consumerist exchange and it is therefore not surprising that some of the respondents in the research from Dyer et al. saw this as an appropriate model of their interaction with dental therapists. However, the consumerist analogy is not entirely fitting – for example, the dental team possesses expertise that the average patient does not and upon which the choice of treatment will critically depend. In the absence of such understanding, perhaps as with other 'purchases' patients choose to rely on proxies of quality to inform their choices. For example, how many of us have convinced ourselves that the big name technical running top we bought is better than the equivalent, cheaper top without the label? The 'labels' we assign to healthcare staff also suggest value, which is in turn the product of our communications about those staff. My point is that patients' views are not created in a vacuum but are the result of an interpretation placed on information derived from the interaction with healthcare. Put simply are we telling patients that a therapist, or hygienist, or any other member of our team will carry out specific treatments because they are the best person to do that – that each member of the team has different skills but equal value? Or are we portraying a model that suggests that skill mix exists to reduce costs? The respondents in this study appear to have acquired the latter perspective, perhaps because talk of money is so much more prominent in dentistry than other healthcare settings.

Commentary 2

The General Dental Council is currently considering whether the requirement for a patient to see a dentist first before care is delegated to another member of the team is an unnecessary restriction. This study is therefore timely in exploring some of the issues arising in relation to direct access to dental therapists. The value of the study lies in the fact that the views expressed by patients were given in in-depth interviews generally in their own homes. What is apparent from the findings is how remarkably little information patients use in determining whether or not they are comfortable with the type of person who provides their care. This reflects what is reported in the wider healthcare literature, that British patients are a long way from being informed, smart buyers.²

The paper describes one of the fundamental issues driving the attitudes of patients regarding their provider as trust. Consumer research would tell us that decisions are driven by both heart (affective) and mind (cognitive) reactions.³ The extent to which choice is determined by cognitive factors depends on the extent of the individual's processing resources; ie patients will vary in the extent to which their view is informed by the 'heart' as opposed to the 'mind'. We should not be surprised then if many patients' base their opinions on whether or not they are happy to be cared for by a dental therapist as opposed to a dentist on general feelings of attachment to particular individual providers rather than because of information about the providers' range of knowledge and technical skill.

In a famous experiment by Harlow,⁴ monkeys were fed on demand from one of two models – one was simply a wire structure with a feeding bottle, the other was cloth covered. Babies preferred the cloth model and spent most of their time with it, even when its milk had run out and milk was still available from the wire model. Patients' willingness to receive care from therapists may defy logic based on equivalence of quality of care. Unless, of course, the patient sees the therapist from the outset and forms an attachment – as may be the case with direct access arrangements.