Piloting the future
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Good things come to those who wait and it might seem the nirvana of skill mix in primary care dentistry may just be seeing a step change towards it.
Some may say it’s about time. The 1993 Nuffield report on professionals auxiliary to dentistry set out the need to develop ‘A differently constituted workforce, running the service more effectively and having auxiliaries providing more skills, including prevention and therapeutic skills’.
In the intervening decades, auxiliaries became professionals complimentary to dentistry (PCDs) and then eventually Dental Care Professionals (DCPs) to encompass the wider team. Also along with that came a requirement to register with the GDC, changes in the Dentists Act, a defined scope of practice and an ever-increasing number of DCP courses up to degree level. This has fostered a new belief in a career pathway for nurses, many of whom found any aspirations they may have had were thwarted by systematic problems, limited access to training and minimal support from colleagues and dentists.
Dental nurses themselves find that the advantages of registration made out for them by pioneering advocates of it were not entirely convincing. Most nurses surveyed did not feel registration had positively affected their views of dental nursing as a career (54.9%) their role (74%) or status within the dental team (86%).
The new NHS contracting arrangements being piloted in England in nearly 100 practices may change that view for dental nurses and the wider DCP team as the direction for NHS travel will be under pinned most definitely by prevention.
It seems only right that this should be the focus of contract reform in the NHS since we are dealing with two largely preventable diseases; caries and periodontal disease. While historically an interventive approach to treating these diseases and the results of them on patients was appropriate and paying the work force in a piece meal way to do it back in the 1960s and 1970s, this is no longer a sustainable model. Our knowledge of the diseases and the epidemiological landscape we see in the 21st century of dental health means that both patients and the government will require a different approach.
So what are the pilots all about?
The Government is committed to introducing a system based on registration, capitation and quality. This is potentially due to be introduced from 2015, possibly phased in over a period of time. It means a fundamental shift in the payment model from one based on activity – unit of dental activity (UDA) to capitation – the number of patients registered within the practice.
The starting point is the oral health assessment which is a detailed clinical review of the patient’s oral health in order to establish the patient’s individual risk status in an objective, evidence based manner.
The oral health assessment determines the risk status of four domains: caries, periodontal health, tooth surface loss and soft tissue health. Patients will have red, amber or green traffic lights assigned to each domain as computed by the software algorithm.
Those traffic lights determine a number of key outcomes:
1. The information given to the patient
2. The preventive treatment and advice provided by the dental team
3. The amount of advanced care the patient is entitled to receive.
For hygienists and therapists this has significant implications. In order to deliver the preventive element of the patient care pathway, dental practices will need oral health educators and hygienists.
A fundamental part of this system is the basic premise that patients will not be able to access advanced care such as endodontics, indirect restorations and metal dentures until their risk factors are controlled. This means poor oral hygiene and high cariogenic diets that are uncontrolled will influence the decision about more advanced care and the role of the team would be to nudge the patients along the care pathway to help them change their behaviours if they want the care. Patients learning to take responsibility for their own health goals is a new driver and hygienists and therapist are uniquely placed to do deliver this.
As skill mix changes in the years to come a practice might find itself with fewer dentists delivering more complex care, therapists providing routine dental care to adults and children with hygienists and oral heath educators supporting patients with gum health as well as other lifestyle advice on smoking, alcohol, obesity and oral cancer.
The new system of payment to practices, not based on activity but based on how many patients are cared for means the payment model for associates will shift to a sessional or salary model. This makes it easier also to pay therapists and hygienists on that same model.
The current UDA system makes it difficult to pay therapists efficiently but there are new and innovative ways of paying therapists in a capitation system. This will require structural changes in the practice and excellent leadership.
The future of NHS private dental care is set to change dramatically in the next five to 10 years. Dental hygienists and therapists will almost certainly be in more demand as the concept of the Team finally takes hold and a career structure of DCPs and primary care develops.
Dr Len D’Cruz BDS LDS RCS MFGDP LLM is an examiner for the MJDF and dento-legal advisor for Dental Protection. He is passionate about postgraduate education and has been an accredited vocational trainer for the London deanery for many years. His practice is an established training practice for new dental graduates. Dr D’Cruz is a postgraduate dental tutor for the Eastern Deanery.