Key Points
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Reports that about a fifth of the adult population in England are dissatisfied with the quality of dental care they receive.
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Highlights the large variation in the quality of dental care experienced by the public, and large differences between population sub-groups.
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Suggests that dentistry is many years behind general medical practice in our understanding of quality.
Abstract
Background There is a lack of evidence and poor understanding of quality measurement and improvement in dentistry. The aim of this study was to undertake a nationally representative survey of the public in England to explore their views on the meaning of quality in dentistry.
Methods A cross sectional survey of the adult population (18 years and over) of England was undertaken. A sample size of 500 was set to provide a precision to plus or minus 5% after allowing for item non-response. A quota sampling approach was used, with predetermined quotas set for sex, age, working status and tenure to ensure the sample was nationally representative. Question selection and design were informed by the literature and a series of interviews with the public. Simple content analysis was used to identify themes in the responses to open questions. Dental service use, gender, age, ethnicity and social class were recorded. Frequency distributions were computed and outputs were cross-tabulated with various population sub-group categories.
Results Five hundred and thirteen people were interviewed. Approximately 20% of patients reported that their care was suboptimal; a third thought it was poor value for money and 20% did not trust their dentist. Good interpersonal communication, politeness and being put at ease were the most important factors that elicited positive responses. Negative factors were cost of care and waiting times. In making an assessment of quality, access (40% of all responses), technical quality of care (35%), professionalism (30%), hygiene/cleanliness (30%), staff attitude (27%), pain-free treatment (23%), value for money (22%), and staff putting patients at ease (21%) all emerged as important factors.
Conclusions Quality in dentistry is multi-dimensional in nature, and includes different elements and emphases to other areas of healthcare. The results will inform the development of a measure of quality in dentistry.
Main
M. Tickle, L. O' Malley, P. Brocklehurst, A.-M. Glenny, T. Walsh and S. Campbell British Dental Journal 2015; 219: E1
Editor's summary
There seem to be periods in dentistry when we are pursued by buzz words. For a time is was audit, then it was leadership and most recently 'quality' has been the issue, particularly spurred on by the quasi-political spectre of choice and value for taxpayer's money.
The difficult question has been, and remains, how does one quantify quality in any meaningful way that can then be applied to the provision of dental care? The authors of this paper have therefore made an impressive start to this process by surveying over 500 adults to ascertain what quality means to them. What has emerged is of immediate value to all of us, quite apart from the way in which it might inform future scales of quality control. The most important positive elements for patients were good interpersonal communication, politeness and being put at ease.
Often described perhaps slightly disparagingly as soft skills, these attributes of an individual and/or the dental team as a whole have nothing whatever to do with technical dentistry. Yet these aspects of our professional pride are the ones which often come top of the list when we ourselves are asked what is quality? The ability to create good margins on restorations, to provide well-fitting prostheses, excellent aesthetic results; these are the measure that we so frequently relate to.
Technical quality was also high on the patients' list, so I must not bias my comments too far in this direction but it remains an important perspective not least given the huge emphasis in terms of time and teaching that we receive on technical skills compared with that on communication, for example.
The results also serve to emphasise how many of the measures of quality rely as much on the work of the dental team as on the dentist. Cleanliness and hygiene, professionalism and staff attitude while driven by vision from the top are nevertheless reliant on good team working and daily attention to detail. This work was intended as a first step in defining quality and it will be valuable to follow the progress of the authors in their future steps to create and test a quality improvement toolkit for use in dental practice.
Stephen Hancocks
Editor-in-Chief
Author questions and answers
1. Why did you undertake this research?
We have undertaken scoping literature reviews which have demonstrated that very little academic work has been published on the nature of quality in dentistry. Our research was undertaken to provide a preliminary national picture of how members of the public,, as the recipients and funders of dental care, view quality in dentistry.
2. What would you like to do next in this area to follow on from this work?
This work has informed the design of a 5-year programme of research to define, measure and improve quality in dentistry. Our goal is to produce and test a quality improvement toolkit to enable dental practices to assess their services and address any areas which require remedial action.
Commentary
Professor Tickle and co-workers state: 'Dentistry is a long way behind primary medical care in its understanding of the meaning of quality and a huge amount of work is needed to develop a definition and a valid measuring system before we can start to implement tested interventions to improve quality of care.'
This paper, while making a valuable step towards tackling this evidence deficit, is a call for this work to begin in earnest.
There are countless definitions of 'quality'. Avedis Donabedian is recognised as having made a huge contribution to our understanding of quality in healthcare. The General Practitioner's Quality Outcome Framework (GPQOF) for primary medical care has been developed with a sound evidence base. However, as Tickle et al. point out, it would be dangerous to assume that quality measures developed for primary medical care can simply be applied to dentistry.
The authors argue that patients and the public are the most important arbiters of quality as the funders (directly or indirectly) and recipients of care. However, they do acknowledge that professional judgements will also play a part in the holistic measurement of quality. This research team asked a representative sample of the adult population of England the specific, but open question: what matters most to you in judging the quality of your dental service?
The responses indicated that access, technical quality, professionalism, hygiene and cleanliness, staff attitude, pain free treatment and value for money where the issues of greatest importance to patient perceptions of quality.
The authors make the valid point that, unlike primary medical care, oral healthcare is not free at the point of delivery for the majority of adult patients in the United Kingdom. This difference understandably (and perhaps helpfully?) conditions dental patients to consider 'value for money' as an important issue in their perceptions of quality. Tickle et al. suggest, correctly in my view, that 'value' should be one of the quality domains for dental practice appraisal.
Other workers have previously established a similar set of patient priorities without asking patients specifically about 'quality' and without the attention given in this paper to establishing a cross sectional representation of the adult population in England. I therefore believe that this work takes us even closer to understanding dental patient priorities in quality judgement. Their call to clearly define quality in dentistry and then to establish the domains in which it should be measured is long overdue.
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Busby, M. A national survey of the public's views on quality in dental care. Br Dent J 219, 118–119 (2015). https://doi.org/10.1038/sj.bdj.2015.597
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DOI: https://doi.org/10.1038/sj.bdj.2015.597