Skill mix – the challenges for practice

Skill mix – what does it mean?

Within dental practice, skill mix is concerned with the combination of different members of the dental team who are used to deliver dental care and services to patients. In his seminal paper, Birch considered that what we should be trying to achieve in healthcare workforce planning is to ‘ensure the right number of people with the right skills are in the right place at the right time to provide the right services to the right people’.¹ This was perhaps more specifically concerned with workforce planning at a macro level, but essentially it also holds true for the individual dental practice delivering care to its patient base.

What that mix looks like in terms of the number of individuals with differing clinical professional titles and competencies will vary from dental practice to dental practice and be determined by the services that the practice provides or wants to offer to its patients. However, it is also influenced by the economic and regulatory framework within which dentistry is delivered, and this will be discussed later in this article.²

Skill mix in healthcare often focuses on its potential to provide better access to services, as well as improving their efficiency and effectiveness. Within the framework of skill mix, two concepts are worthy of consideration; those of:

There have been several examples of enhancement from within the wider healthcare community in the UK over the last few years, including the development of the role of the advanced practice nurse, the consultant nurse within the hospital sector, developing the role of healthcare assistants to take on some of the competencies traditionally undertaken by nurses and, most recently, the development of the surgical care practitioner in an enhanced role for nurses in a surgical team enabling him/her to undertake some surgical procedures.^3,4 In terms of labour substitution, a 2005 Cochrane systematic review into the substitution of doctors by nurses in primary care found that patient health outcomes were similar for those treated by nurses and doctors, with patient satisfaction slightly higher with nurse led care.⁵

A dental workforce that includes a range of dental auxiliaries to help deliver preventive and therapeutic dentistry was first formally discussed in the Nuffield Foundation report into the education and training of dental auxiliaries as long ago as 1993.⁶ However, the expansion and development of this group, more recently termed dental care professionals (DCPs), in the delivery of dental services has been painfully slow.

One objective for the publication in 2009 of the Scope of Practice by the General Dental Council (GDC) was to clarify the range of clinical competencies that each individual member of the dental team could undertake.⁷ It has been subject to revision since then and the extensions to skills and duties permitted of different groups within the dental team allow for some skill mix development through both enhanced skill set and substitution (DCPs permitted to undertake more of the skillset of a dentist). In addition, in 2013, the GDC permitted ‘direct access’ of patients to DCPs under certain defined circumstances,⁸ with the consequence of further facilitating the potential for enhancement and substitution. However, at the present time this is not possible within the current NHS structure as there is no opportunity to allow for any registrants other than dentists to open courses of treatment.

While it was not necessarily the norm to educate the members of the dental team to work together with regard to patient care a few years ago, graduate hygienists, therapists and dentists are now leaving dental school with more of an appreciation of each of their various roles and skill sets through the development of curricula designed to integrate and encourage a skill mix approach to patient care. To embed this integration of dental team members right from the outset of training certainly appears logical, and it is also now a GDC stipulation and one of the roles and responsibilities of education and training providers that they should ensure, ‘The importance of dental team working, with opportunities for students to train and work with other dental professionals’ occurs within the delivery of the curriculum.⁹

The economic considerations of utilizing a skill mix approach in dental practice

The business case for employing a dental hygienist or therapist is usually influenced by the funding structure of the practice in some way. Those who work in the private sector, where the fee for their activities can be set by the practice, should receive an adequate remuneration in relation to this fee.

There is, however, little evidence for a similar model being used to reward therapists for their ‘substitution’ restorative competencies.¹⁰ It is salient to note at this point that it is often misquoted that dental therapists can undertake simple fillings or restorations only,¹¹ when, in fact, the GDC Scope of Practice publication details that dental therapists can undertake ‘direct restorations on primary and secondary dentitions’ and on probing further into the GDC's curriculum document for dental programmes; Preparing for Practice, indicates that dental therapists in training and undergraduate dental students are both trained to:

Most of the graduate dental therapists from the University of Essex not only utilize these skills post registration in their practices, but some are engaged within their practice set-up to take referrals for direct restorative procedures, including most aesthetic anterior composite restorations. Why should this not be the case as the undergraduate training in this area, both pre-clinically and clinically, is usually very similar for undergraduate therapists and dentists, with the therapists often having the opportunity on their programmes to undertake many more direct restorative procedures than their dental undergraduate counterparts, who are busy achieving a range of additional clinical competencies?

When dental therapists work in the private sector, where the fee for their various activities, including restorative procedures, can be set by the practice, in essence a fee per item system, the practice can generate a viable income stream through the setting of appropriate fees and therapists should again be able to receive an adequate remuneration in relation to the procedures that they have undertaken.

Within the current GDS arrangements, hygienists and therapists do not have performer status, and therefore cannot individually generate NHS-derived income. Referral to hygienists and therapists may occur, but associate dentists may be less inclined to do this as they may not receive Unit of Dental Activity (UDA) payments associated with the referred patients' treatments and doing so is often considered complex, being difficult to administer the split in income between the various members of the team who have been involved in the delivery of a course of treatment.¹¹ Outside of the English NHS UDA system, such as in Scotland, the general principles of how a fee per item system could lead to remuneration for dental hygienists and therapists from the income generated from their activities, as alluded to previously, would also follow. However, as the level of remuneration in such a system is set external to the dental practice, this presents an economic constraint and could have a bearing on whether the level of remuneration being offered to these DCPs would be competitive with those working in a private practice environment.

NHS pilot and prototype practice arrangements

Interestingly, evidence from the NHS pilot scheme suggested that involved practices saw a much greater role for DCPs, with 50% of pilot practices indicating that they would want to increase the use of therapists within their skill mix.¹² Some also indicated that they would prefer to employ dental therapists in the place of associate dentists for economic as well as for benefits in prevention, behaviour management and maintenance that hygienists and therapists are able to undertake with patients.¹¹ Indeed, the following is indicative of many of the responses from pilot practice owners that were received when undertaking preparatory interviews prior to a presentation on skill mix at last year's BDA conference.

Some of those currently involved in the NHS prototype practice arrangements who were previously involved in the pilot scheme arrangements have intimated that their experiences of the benefit of skill mix in their practices from the pilot arrangements continues within the prototype arrangements, where there still appear to be significant opportunities for a large proportion of patient care to be provided using a skill mix approach.¹⁴

There are two broad versions of prototype:

They are intended to move away from the Unit of Dental Activity (UDA) system, under which primary care in England has been working, towards prevention rather than a mechanism to be remunerated by activity.¹⁴ The basis for these prototypes, as was the case with the previous pilots, is a capitation system, whereby practices are primarily measured by their ability to retain a measured number of patients based on historical figures. However, although the system is based on capitation, there is also an activity element and this is a significant departure from the mainly capitation-based previous pilot schemes.

Skill mix manpower to deliver dental services

Results from the most recent Adult Dental Health Survey in England, Wales and Northern Ireland indicated an older population retaining an often heavily restored dentition for longer, and a reduction in dental disease in the remaining majority of the population.¹⁷ It has been inferred that, whilst the remedial operative dentistry of often increasing complexity (beyond that of the existing scope of a dental therapist) on an older population could be provided by dentists,¹⁰ DCPs should provide a large contribution of the required preventive care and moderate level interventions to the majority of the population.¹⁸

This UK pattern of disease burden is mirrored in several other European countries that have been adapting the numbers of dental nurses, hygienists and therapists in the workforce to address these changing and developing demands. For example, in the Netherlands, dental schools train the same number of dental students and therapy students each year and this has been the case since 2002.¹⁹ In the UK, approximately eight times the number of dentists as dental therapists are still trained.²⁰ In addition to the approximately 1700 UK trained dental graduates joining the Register each year, a further 900 overseas or EEA qualified dentists join, with practically no overseas dental therapists joining the Register. So effectively, the ratio of new registrants is in the region of one new dental therapist for every 13 new dentist registrants.²¹ Even given the developing requirements and complexity of treatments required to be undertaken by dentists on an increasingly older population who are keeping their teeth for longer, and the future requirements for specialists and those able to provide advanced care to patients beyond the moderate level of interventions required for the majority of the population, these additions to the available clinicians appear imbalanced and counterproductive to the widespread adoption of skill mix. Certainly, there is also potential for significant economic savings to be made through training (and then later remunerating) more dental hygienists and therapists and fewer dentists to provide oral healthcare services in the future, and this is undoubtedly an attractive proposition for those responsible for using a taxpayer-funded resource to commission the training of and remunerate a workforce to deliver the service.

What do patients think about skill mix

It is also important to consider the patient's view of who provides their oral healthcare service. Some of the resistance to both the more widespread use of DCPs and use of their competencies within practice is derived from a concern with how patients would view any substitution of activities to DCPs from dentists. If we look at the dental therapist as an example, the evidence in the literature broadly suggests that patient satisfaction ratings for dental therapist care are as good and often better than for care by dentists,^22,23 though this satisfaction can be influenced by patient perceptions of consistency, familiarity and trust within the dental team, and with regards to the latter, trust in the delegating dentist appears particularly important to patients.²³

The future of skill mix in dentistry

So what of future opportunities for skill mix in dental practice? There are many interesting areas to consider, some of which are starting to be seen happening now and others that may very well come to pass in the near future.

The GDC's Scope of Practice document has already been revised and we are likely to continue to see an evolution of competencies that the various registrants are permitted to undertake with appropriate training. In the UK, we are now seeing clinical MSc programmes aimed at dental hygienists and therapists; including the MSc in Advanced Minimum Intervention Dentistry at KCL and the MSc in Advanced Periodontal Practice at Essex, the latter including a periodontal surgical module where hygienists and therapists learn about periodontal surgery; including indications for periodontal surgery and various alternative techniques. This provides them with advanced knowledge, so that they are able to appreciate when surgery may be beneficial for patients in their care. They also undertake surgical training in simulation during their training and, unsurprisingly, they are equally as adept in this practical area as their dentist colleagues studying alongside them on the MSc Periodontology programme. Were this to enter the scope of a dental hygienist or therapist who has undertaken appropriate training in the future, this could enable considerable change within practice to enhance the care it could offer to its periodontal patients.

Dental nurses as a professional group have the largest number of registrations with the GDC, at approximately 55,000, and their role within the UK to date has largely been associated with supporting clinical colleagues within the dental setting.²¹ The extended duties dental nurse; a qualified dental nurse who has undertaken further training in a variety of areas such as fluoride applications, impression taking, undertaking plaque scores, dental radiography and photography, is a concept that is currently receiving much interest because of the opportunities it provides to deliver prevention within, for instance, the pilot/prototype arenas.¹⁴ There is also, however, currently a Government-supported Trailblazer Apprenticeship Standard under development to train an ‘Oral Health Practitioner’; a dental team member whose role will very likely involve not only that of an extended duties dental nurse, but also being able to undertake smoking cessation, oral health education within practice as part of a community health team, and to be able to take blood from patients.²⁴ This last competency might appear surprising though, when we consider the dental practice as a setting for screening for conditions affecting oral and general health, such as for diabetes, perhaps less so.²⁵

What about screening for more familiar conditions affecting oral health, such as dental caries – traditionally the preserve of the dentist? Will this be the most efficient and effective use of dentists' time, skills and competencies in the future? The findings of some interesting research conducted recently looking at the abilities of different members of the dental team to screen for occlusal caries clinically, following a brief 5 minute training session, make for interesting reading. The sensitivity for correctly predicting diseased teeth and the specificity of correctly predicting healthy teeth being broadly the same across dentists, hygienists, therapists and dental nurses, with the dental nurses group exhibiting the highest sensitivity of predicting diseased teeth.²⁶

Conclusion

This article has sought to define the conceptual understanding of skill mix and to consider the opportunities for adopting and utilizing a skill mix approach to the delivery of dental services to patients under differing funding mechanisms. By far the largest of these is through the NHS and the challenge here appears to be adopting national policy, funding and commissioning arrangements that create an environment where change is an appealing prospect for both the dental practice and each of the individual team members who work within it. Finally, some examples have been chosen to challenge some of our conventionally held wisdom surrounding who provides what aspects in the delivery of dental care to our patients. Stimulation of discussion and debate in this area is an essential and healthy pursuit in which our profession should engage.