Direct access to midlevel dental providers: an evidence synthesis

Brocklehurst, Paul; Mertz, Beth; Jerković-Ćosić, Katarina; Littlewood, Anne; Tickle, Martin

doi:10.1111/jphd.12062

Cited by 19 publications

(18 citation statements)

References 41 publications

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“…8,69,72 The importance of lay perspectives on the quality of health services, particularly its acceptability, is increasing, 23,73,74 especially where there are plans to extend the use of skillmix. [75][76][77] Given the recent enhancement and innovation of the remit of DAs in certain countries, including the introduction of direct access, 26,78,79 it is surprising that high quality data do not exist to inform these policy decisions. Moreover, a paradox exists where quality frameworks assert the primacy of public and patient perspectives, yet policy decisions about the reorganisation and delivery of care have been made in the absence of high quality evidence of the acceptability of using DAs.…”

Section: Discussionmentioning

confidence: 99%

“…Although there have been recent policy and regulatory changes in some countries to facilitate the use of DAs, 26,71,79 high quality evidence is required to inform policy-makers and the dental profession of their legitimacy. 20,80 In addition, the dental profession, notably in the US and Canada, hotly debates DAs enhancing and innovating their skills and remit.…”

Section: Discussionmentioning

confidence: 99%

“…22 A service's social acceptability and legitimacy would be particularly important where DAs' permitted duties are to be extended to new patients and supervision reduced. [24][25][26] Our recent Cochrane review identified no high quality studies comparing the acceptability of care provided by DAs and dentists. 9 The review excluded studies on social acceptability and legitimacy.…”

mentioning

confidence: 99%

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The acceptability of care provided by dental auxiliaries

Dyer

Robinson

2016

The Journal of the American Dental Association

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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The acceptability of care provided by dental auxiliaries

Dyer

Robinson

2016

The Journal of the American Dental Association

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“…[73][74][75][76][77][78][79] Treatment outcomes for atraumatic restorative techniques were also similar across a number of criteria for single-surface (small) and multisurface (large) restorations for DCPs and GDPs. 72 In a review of the literature on direct access, 80 DCPs were again found to perform to a similar standard as GDPs, although the evidence base found by Dyer et al 72 and Brocklehurst et al 80 was mainly descriptive with only a few experimental studies.…”

Section: Organisation Of Nhs Dentistry In Primary Carementioning

confidence: 99%

Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study

Brocklehurst

Birch

McDonald

et al. 2016

Health Serv Deliv Res

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BackgroundMaximising health gain for a given level and mix of resources is an ethical imperative for health-service planners. Approximately half of all patients who attend a regular NHS dental check-up do not require any further treatment, whereas many in the population do not regularly attend. Thus, the most expensive resource (the dentist) is seeing healthy patients at a time when many of those with disease do not access care. Role substitution in NHS dentistry, where other members of the dental team undertake the clinical tasks previously provided by dentists, has the potential to increase efficiency and the capacity to care and lower costs. However, no studies have empirically investigated the efficiency of NHS dental provision that makes use of role substitution.Research questionsThis programme of research sought to address three research questions: (1) what is the efficiency of NHS dental teams that make use of role substitution?; (2) what are the barriers to, and facilitators of, role substitution in NHS dental practices?; and (3) how do incentives in the remuneration systems influence the organisation of these inputs and production of outputs in the NHS?DesignData envelopment analysis was used to develop a productive efficiency frontier for participating NHS practices, which were then compared on a relative basis, after controlling for patient and practice characteristics. External validity was tested using stochastic frontier modelling, while semistructured interviews explored the views of participating dental teams and their patients to role substitution.SettingNHS ‘high-street’ general dental practices.Participants121 practices across the north of England.InterventionsNo active interventions were undertaken.Main outcome measuresRelative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients.ResultsThe utilisation of non-dentist roles in NHS practices was relatively low, the most common role type being the dental hygienist. Increasing the number of non-dentist team members reduced efficiency. However, it was not possible to determine the relative efficiency of individual team members, as the NHS contracts only with dentists. Financial incentives in the NHS dental contract and the views of practice principals (i.e. senior staff members) were equally important. Bespoke payment and referral systems were required to make role substitution economically viable. Many non-dentist team members were not being used to their full scope of practice and constraints on their ability to prescribe reduced efficiency further. Many non-dentist team members experienced a precarious existence, commonly being employed at multiple practices. Patients had a low level of awareness of the different non-dentist roles in a dental team. Many exhibited an inherent trust in the professional ‘system’, but prior experience of role substitution was important for social acceptability.ConclusionsBetter alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical.Study limitationsOutput data collected did not reflect the quality of care provided by the dental team and the input data were self-reported.Future workFurther work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…[49][50][51][52][53] The need for health system reform in order to support the application of enhanced skills in practice to improve patient care was identified with a continuous programme of training to be established rather than a one-off course.…”

Section: Professional Developmentmentioning

confidence: 99%