The changing skill mix – experiences on the introduction of the dental therapist into general dental practice

Key Points

• Developing a strong commitment to teamwork is a key challenge to the dental profession.

• Dental therapists can play an increasingly important role in the provision of dental care within general practice.

• Integrating the dental therapist has many benefits but creates challenges and responsibilities within clinical practice, training team management and regulation.

Abstract

Health need and demand are outstripping the capacity of the established professions to provide full and responsive services. In these circumstances attention has turned to the role of allied and complementary professionals in all aspect of health provision, not least dentistry. It is in this context that the role of the dental therapist is coming to be of increasing significance to the dental services.

Main

Following the publication of NHS dentistry: Options for change in August 2002¹ a Modernising Dentistry Programme run by the NHS Modernisation Agency was set in motion. Its aim was to engage the dental profession in a process of change that would deliver a fundamentally different NHS dental system. To this end, dentists who wished to explore new ways of delivering dentistry were invited to submit bids to the Department of Health outlining their ideas. I recognised an opportunity to attempt a different way of working and my bid, which was seen as consistent with the direction of national policy on the modernisation of the NHS workforce, was accepted and my practice, School Lane Dental Practice, became a Field Site.

The Field Site objectives were to:

• Test a new method of remuneration for GDPs as an Options for Change field site

• Maintain access to NHS dentistry.

• Improve oral health and encourage health promotion

• Encourage a preventative, patient-centred approach to dental care

• Improve quality of care and quality of patient experience

• Improve working lives for dentists and dental teams

• Reduce frequency of recall using a decision support grid to determine recall intervals

• Make maximum use of Professionals Complementary to Dentistry (PCDs) [now DCPs] using the best skill mix available for routine care

• Adopt a preventative approach to oral health using the skills of the oral health educator. Additionally, support primary care initiatives to improve nutrition and diet, and reduce smoking, alcohol and substance misuse.

A Personal Dental Services (PDS) contract provided me with both the opportunity and incentive to meet these objectives by creating a new skill-mix which optimised the use of the practice staff with the dentist delegating some areas of care to Professionals Complementary to Dentistry.

The skill-mix challenge

Baltutis and Morgan² reviewed the literature on dental auxiliaries and their future roles, looking at legislative factors, productivity and quality assurance. They advocated that dentists in highly industrialised countries should be guided, through expanded opportunities for retraining and continuous education, into undertaking more complex technological procedures. Less complex procedures could then be undertaken more economically but equally well by various categories of auxiliary personnel.

In my practice, I had a highly motivated group of qualified staff, some of whom had been with me for many years (dental hygienist, oral health educator, DCP with a certificate in dental radiography). I felt that their full potential was not being realised and that they could do so much more to enhance the patient experience within the practice and change the emphasis from one of treatment to one of prevention, which, at the time, appeared to be one of the DH's aims. Subsequently when one of the dentists left I took the opportunity to replace him with a dental therapist and a dentist from the specialist list.

In this multidisciplinary approach the focus is on all team members, including the dentist(s), working together and respecting each other's skills, knowledge and distinctive areas of competence. As Pirie et al.³ argue, it is important for the team members to understand their separate but inter-related roles and their dependence on their colleagues in focusing on complementary procedures and perspectives.

However, as interest in inter- and multi-professional working has increased in many areas of health service work, the emerging evidence suggests, in dentistry no less than other settings,⁴ that neither professional groups nor individual practitioners find this an easy task. Difficulties arise in three areas of the practice landscape:

The structural context: existing professionals may fear the prospect of finding themselves with 'new' professionals in a market place and vying for the same resources. This leads to protectionism when sharing of resources is actually what is required.

The cultural context: different interests, professional values and occupational cultures can militate against collaboration. As a result, staff are reluctant to collaborate in the face of what can be perceived as challenges to their identity and sphere of exclusive activity.

The skills context: there has been little investment in developing the capacity of institutions or the skills, knowledge and attitudes among staff which are needed if they are to work collaboratively. Processes and skills for creating clarity, becoming explicit about roles, and developing working arrangements, are underdeveloped.⁵

Each of these areas has been reflected, explicitly or subliminally, in the challenges we have faced in reorienting our practice to meet the objectives of the field site.

The dental therapist

Since July 2002, therapists have been able to work in general dental practice and it is my experiences with this role on which I wish to focus.⁶ Dental therapists are recognised as a Dental Care Professionals. The GDC's guidance to therapists formerly contained in Maintaining standards⁷ (which was current at the time of setting up this field site) detailed the treatments a therapist can lawfully carry out. At the time of writing, therapists can only carry out treatments which have been delegated to them by a dentist, although, since 202, providing they have undertaken suitable training, their prescriptive duties have been extended, reflecting their increased significance in the provision of dental care. Although this may change under proposed GDC Guidance,⁸ at present, therapists' autonomy is strictly circumscribed and they are able only to work under prescription. For example a therapist can only carry out a simple filling provided that it does not involve the pulp, a laboratory procedure or pinned retention and can only administer an ID Block under the direct supervision of a dentist. Thus, the dentist must be on the premises.

The School Lane therapist trained at a dental school in a course lasting 27 months, with half the time devoted to clinical practice, meaning that there was plenty of hands-on experience.

According to the Workforce Numbers Advisory Board, in November 2004, there were 348 dental therapists on the register although, at the present time, there are very little data on how many are in general practice. It was felt in the report that the registered number was not truly reflective, as dental therapists can often earn significantly more in practice concentrating on hygiene. Consequently, dually qualified therapists are not registering on both the therapist and hygienist registers for financial reasons.

Benefits of introducing the role of dental therapist into general dental practice

The routine nature of many visits to the practice means that the therapist can increasingly take on a range of duties from dentists, recognising the limitations outlined above, in order to free up our time for more technically demanding work. It has been extremely refreshing to work with the therapist, newly out of dental school, who is well trained in patient management and patient education and in using the least invasive techniques in restorative work.

In a recent interview,⁹ the GDC President said that in many practices therapists spend three-quarters of their day scaling and polishing. In our practice the therapist has an undifferentiated caseload separated out only on the type of restoration required. This means that the selection of patients to be referred to her is based on the GDC criteria only, not on other considerations such as complexity of patient management. In this way the therapist is a full member of the team in clinical delivery differentiated only by permitted areas of clinical activity.

My dental therapist had previously worked as a dental nurse, oral health educator and practice manager. Through her capacity to empathise and relate to the work of the other DCPs, in my view, working standards of these team members within the practice have been raised. There has been an added advantage of having somebody to act as a go-between between myself and the dental nurses.

Drawbacks to introducing the role of dental therapist into general dental practice

It has not been easy to manage change and address clinical commitments at the same time and I am sure that practice owners will sympathise with the fact that the volume of day-to-day work has not freed up much time for me to implement the new way of working. It has not been easy to maintain current organisational arrangements, influence others to move from their comfort zone and give them the freedom and space to undertake new roles effectively.

Clinically, my working day has become more onerous with almost every restoration involving the loss of a cusp or a root canal treatment. The limits on treatment provision and the necessity for being on the premises for an ID block can prove an administrative headache.

Currently the dental therapy training places are drawing from qualified dental nurses and hygienists. This will inevitably cream off the more ambitious and those with most initiative. Who will then back-fill nurse posts in the practices? There is already a serious shortage of entrants into dental nursing and high rates of nurse turnover. The current crisis in achieving adequate numbers of nursing staff may well be exacerbated.

Harris and Burnside¹⁰ have suggested that dental therapists are not cost effective in general practice. However my experience leads me to concur with Holt¹¹ that this is a result of assessing therapist activity purely on a quantitative, item for service, basis. Such an approach does not put a value on what one might call the 'whole therapist package' with its emphasis on patient management and education geared towards prevention.

The impact that the introduction of the dental therapist has on service quality and service improvement

The prescriptive nature of the dentist-therapist relationship, and the fact that the dentist is fully responsible for the therapist's work, has led me to introduce care systems and pathways as advocated by the NHS Modernisation Agency.¹²

Now that the therapist is undertaking procedures which historically have been in the domain of the dentist, this has resulted in the focused deployment of dentist specialist skills. For her part, the therapist deals with oral health education, periodontal problems and restorative work in one appointment. As a result of her training, she has revealed a more imaginative approach to delivering oral health information than had the dentists previously. This has highlighted the patients' personal responsibilities for their continuing oral care at home. A patient survey which we have undertaken has revealed that, since the introduction of the therapist, patients feel that they have been advised more effectively than they had been previously by the dentist. In addition, patients have commented favourably and extensively on the communication skills of the therapist.

Factors which improved the integration of the therapist into the practice

The School Lane therapist had not worked within the NHS for some time and so an important part of the induction arrangements was to familiarise her with the regulations, structure and organisation of the NHS.

Concurrently, the dentists, so that they might prescribe appropriately, had to gain awareness of the therapist's knowledge and previous experience. In addition, we had to be available and approachable to discuss cases and to be called on if any concerns arose. As with any working relationship it is critical to build a mutual trust and to establish understanding and confidence in each other's practice.

Pre-referral assessments need to be thorough and radiographs are evaluated carefully so that when the therapist is carrying out restorative treatment there is little risk of pulpal involvement. We developed strict protocols for referral.

The therapist was accustomed to working on prescription in the dental hospital. Figure 1 shows examples of the stickers (colour-coded for each dentist) that, at the therapist's suggestion, we now use on the record card to facilitate our prescriptions. These were derived from protocols used by the therapist at the dental hospital during her training.

Figure 1

Examples of colour-coded stickers

We carried out a systematic audit of appropriateness of our referrals and there have been ongoing discussions between the two dentists and the therapist to ensure this.

Factors which impeded the integration of the therapist into the practice

In our long established practice, where patients had been attending for many years, not all patients were immediately content to be referred for treatment to the therapist. To address this, introductions were planned and, in partnership with the PCT, a communications strategy devised to explain the nature of the Field Site. This involved a leaflet posted to all patients, notices in the practice, explanatory information on appointment cards and a waiting room information video.

At a personal level, I can identify with the findings of Goodwin et al.¹³ which suggested that, within the PDS pilots, dentists failed to share feedback about practice developments with the DCPs. To do so involves a preparedness to share power. This is a problem not unique to dentistry and one that bedevils the development of multi-professional working across the health sector.¹⁴ The financial structure of general dental practice and the nature of the practice owner's interest can only reinforce this issue. It will be a huge challenge to engender the culture shift required to share power and so develop successful multi-disciplinary teamwork.

Whilst the cultural reservations of the dental profession to allow anyone else to undertake work which has traditionally been the domain of the dentist did not affect my commitment, on a wider canvass there is still resistance to the expansion, even introduction, of therapists. The therapist is well aware of this and requires constant reassurance that her role and position are secure.

What issues does the experience of introducing the therapist into the practice raise in respect of dentist and therapist training and for regulation?

Dental therapists are currently enrolled with the GDC and the registration of other DCPs is imminent. This should not only raise standards in practice but also enhance the profile of dental therapy training. Mossey¹⁵ re-emphasises the importance of interaction and reciprocation between those involved in the delivery of the dental services as a whole and those educating the dental team, stating that 'professions complementary to dentistry need to be recognised for their contribution to the educational process.'

The therapist working in the School Lane Field Site felt that there should be more interaction and collaboration between dental students and therapy students who she saw as having similar training needs. She felt that she had an advantage in integrating into our team due to the various experiences she had in dentistry prior to her therapist training. She identified a need for teamwork education at dental school. Newton et al.¹⁶ have suggested the introduction of training in workplace management and team communication skills into the undergraduate curriculum.

The practice therapist and I both felt that, within undergraduate and pre-qualification training, relationships and interdependence with colleagues are extremely significant. It will be important to devise training schemes which focus on the whole dental team as a multi-professional unit, where professional issues involved in working together are addressed and where the benefits of working in such a group are championed.

In an interview,¹⁷ the Registrar of the GDC, discussed commonalities in the building blocks, such as some areas of science and issues to do with confidentiality and consent, which provide common ground across the curricula of DCPs and dentists. Suitable training modules for therapists alongside dental students and a transferable credit system would, using the Skills Escalator model, provide a pathway for DCPs to progress into new areas of enhanced responsibility and even eventually become dentists, if they so wished. This would mean adopting more widely the modular approach to educational provision which is now well established in many areas, including those associated with healthcare.

However, as yet there is no clear framework for continuing professional education for dental therapists and there is no requirement of the GDC for compulsory CPD until 2008 Funding streams need to be identified, personal development plans for therapists put in place and post qualifying training needs to be quality assured and performance managed. The therapist at School Lane has reported difficulties in finding suitable on-line resources and accessing specialist courses relevant to her needs. However, both the BDA (Vital) and the FGDP (Primary Care) have begun to produce journals for the whole dental team and the British Association of Dental Therapists provides a journal, regular meetings and study days and has set up a website.

For our part, GDPs have the responsibility to set Personal Development Plans which include attaining competence in working effectively within the dental team. In addition, as employers and team leaders, we have the responsibility to ensure that all our staff members are engaged in their own personal development. The Postgraduate Dental Deans working through the tutor network have responsibility for delivering training. Certainly, within the East Midlands, there is a focus on training for the whole team.

Educational needs of the dentist

The GDC views these needs as a three-dimensional challenge.¹⁸

Increasing breadth across the dental team

Gallagher and Wright¹⁹ believe that, in general, 'dentists have little knowledge of the training and work practices of dental therapists.' Indeed, the recent South Yorkshire Dental Workforce Survey of Primary Care Dentists²⁰ suggested that dentists may require training on the management of larger teams and on the deployment of DCPs in practice to increase efficiency. Batchelor,²¹ who reviewed the Gallagher and Wright paper, felt that there was a governance issue which the GDC could address by providing all registrants with details of what activities each grade of DCP can and cannot undertake and the level of supervision required.

In the now superseded GDC document Maintaining standards⁷ there was a section on developing the dental team which contains the curriculum framework for all DCP groups and there has been a recommendation from the GDC that greater attention needs to be given to team working in the undergraduate curriculum.¹⁸

In my case, it was only from within the Field Site that I gained insight into the professional issues and advantages of working together with a therapist.

Vertical integration within and between specialities

The emergence of the group of professionals who may be able to undertake much of the routine dentistry among the child and adult population means that the highly developed skills in which dentists have been trained can be more effectively deployed. It also gives dentists the opportunity to develop specialist skills which will be formally recognised.²² Consequently, the patient will be placed in the hands of the dental professional who is most appropriately qualified to carry out the job.

Wilson²³ felt that 'there is a need for many more specialists' and called for 'new organisational systems to support the education and training and subsequent lifelong learning of future members of the dental team, as well as to satisfy the need to take advantage of new exciting technologies'. However, he noted that, for all this, there is a cost which presently is not being met.

Expansion longitudinally with lifelong learning and continuing professional development

Sanderson²⁴ states that 'Undergraduate and postgraduate education of dentists is required to be updated to keep pace with ongoing development within the profession. Increasingly specialisation requires new educational initiatives and CPD is an ongoing requirement for all registered members of the dental team.' She argues that, by highlighting team training as a priority in our personal development plans, general practitioners can influence the use of the training budgets for general dental practice. Moreover, if the oral health care of the population is seen by the government to be best delivered via well trained teams, then team training must become a priority for these budgets.

Gender issues

In the current environment, competition to retain staff is high. With the dearth of suitable staff, still largely women, imaginative ways need to be developed of persuading people back to work, before they become de-skilled. Following their survey of PCDs in general practice, Sprod and Boyles concluded that more attention needs to be paid to the reasons for recruitment and retention difficulties among the dental team.²⁵

At School Lane we have tried hard to build a family friendly approach which has gone hand-in-hand with flexible working hours, which suit not only staff but also patients. We are currently struggling with the partial offset of the cost of Nursery Education against National Insurance Payments. More bureaucracy, but I think it is valued by the staff group.

Currently, prior work experience in dentistry is a desirable criterion for selection for dental therapy training. Consequently the majority who embark on therapist training are drawn from qualified dental nurses and men are very much in the minority.²⁶ Indeed the conclusions of a national survey²⁷ reveal an assumption that dental therapists will continue to be female. In these circumstances, I agree with the survey's recommendations that there should be openings for part-time training and also an enhanced opportunity to take a career break at some point in their lives, for those with family commitments. In addition, there can be problems with access to CPD where geographical location of course centres requires lengthy travel and difficulties with evening and weekend courses because of child-care responsibilities.²⁸ We need to adopt a 'family friendly' approach to the organisation of training and CPD. These issues mirror those for women dentists, fully documented in the Seward Report in 2001.²⁹

Elsewhere in the NHS, as the salary structure is becoming more rewarding and career pathways are being extended, there are more men qualifying in general nursing. However, DCPs are still very largely women and are often undervalued. Should it not be possible to draw a wider range of candidates into training and widen participation by increasing the significance and profile of the complementary professions? Using dental therapy for example, this could be achieved by marketing more strongly the very reasonable pay and conditions available to dental therapists in general practice and by affecting a culture change so that the role of the dental therapists is not perceived as ancillary but is marketed robustly as an attractive career option.³⁰

Clinical governance

Clinical governance for dentists is already firmly in place. At School Lane, the dentists and therapist have been developing a basic framework for assuring the quality of the therapist's clinical practise:

The therapist's work can be reviewed by the DRO in the same way as that of a dentist

She is party to all patient feedback and involved in reviewing any work that might require replacement

By reviewing prescriptions, discussing cases, and reviewing patient notes, we feel that we are able to monitor satisfactorily, as a team, our own prescribing and the therapist's practise in response

At present there is no clear framework for continuing dental education and few openings locally for her to top up her skills

The dearth of therapists in the vicinity means that there is little opportunity for peer-review

Auditing of her radiographs has taken place within the practice and clearly there are opportunities for other audits

We are evolving a framework for the therapist's appraisal.

Conclusion and thoughts about the future

There will be a continuing need to monitor and evaluate the activity of the School Lane Field Site and the clinical practice of the dental therapist and to continue to collect patient feedback. As more therapists come on stream, it will be interesting to compare our experiences with those of other practices.

Given that my main aim was to alter the skill mix of the practice and, given the empirical nature of the Field Sites, I had assumed that the GDC would be flexible in relation to the activities of the DCPs. However, this was not the case and the hygienist and therapist have been able only to undertake the prescribed list of duties as laid down by the GDC⁷ at the time of the Field Site.

However, times are changing. By means of a Section 60 Order, our regulators now have the power to change the Dentists Act to reform and strengthen the GDC and expand the register of the DCPs. Therapists will then be able to operate according to their competence and training, so moving away from their closely defined list of duties. In this context there will be a need to reconfigure and develop clinical governance procedures in order to monitor the extended role of the therapist. It will also bring into sharper focus the structural, cultural and skill development challenges which will have to be addressed if multi-professional practice is to become embedded effectively in the dental landscape. Herein lies a new agenda for those responsible for pre registration training and CPD.

What should be the priorities for investment in training? Wilson²³ has questioned whether there should be increased numbers of dentists or whether alternatively any increase in training places should be distributed between both dentists and DCPs. The previously quoted survey by Sprod and Boyles²⁵ concluded that long-term workforce planning is likely to remain an imprecise science. This takes us back to the fundamental questions about dental provision which prompted the experiment in which School Lane has participated. These are as much political as professional concerns and the situation remains uncertain. Nevertheless, it remains important to monitor workforce issues to ensure that short-term decision-making is as well informed as is feasible.

As pointed out by Lambert-Humble³¹, in New Zealand dental therapists are now allowed to diagnose and carry out their own treatment plans. This follows the model in medicine of referral upwards to specialist expertise of conditions outside the diagnostic and treatment capabilities and training of the nurse practitioner, whereas UK dentistry currently operates a downward referral model with the dentist carrying out all diagnosis and treatment planning. Which is to be the shape of clinical dental practice in the twenty-first century?