Harry Hill

The technical efficiency of oral healthcare provision: Evaluating role substitution in National Health Service dental practices in England

OBJECTIVES In many countries increasing use is being made of dental care professionals (DCPs) to provide aspects of clinical activity previously undertaken by dentists. This study evaluates the differences in practice efficiency associated with the utilisation of DCPs in the provision of General Dental Services in the National Health Service (NHS) in England. METHODS One hundred twenty-one NHS practices completed a questionnaire and shared practice information held at the NHS Business Services Authority. Practice efficiency was estimated using data envelopment analysis with the robustness of the findings checked using Stochastic Frontier Model estimation. RESULTS Dental practices operated at an estimated mean level of technical efficiency of 64%. Variations among practices in the use of DCPs were not associated with variations in practice efficiency after controlling for other staffing levels, patient population characteristics and practice variables. CONCLUSIONS The current NHS dental contract limits the potential for efficiency improvements by setting annual practice activity targets that produce little incentive for role substitution. Whilst DCPs may by practising efficiently, this is not reflected in practice-level efficiency, possibly because of dentists using the time released for other non-NHS activity.

Does capitation affect the delivery of oral healthcare and access to services? Evidence from a pilot contact in Northern Ireland

BackgroundIn May 2009, the Northern Ireland government introduced General Dental Services (GDS) contracts based on capitation in dental practices newly set up by a corporate dental provider to promote access to dental care in populations that had previously struggled to secure service provision. Dental service provision forms an important component of general health services for the population, but the implications of health system financing on care delivered and the financial cost of services has received relatively little attention in the research literature. The aim of this study is to evaluate the policy effect capitation payment in recently started corporate practices had on the delivery of primary oral healthcare in Northern Ireland and access to services.MethodsWe analysed the policy initiative in Northern Ireland as a natural experiment to find the impact on healthcare delivery of the newly set up corporate practices that use a prospective capitation system to remunerate primary care dentists. Data was collected from GDS claim forms submitted to the Business Services Organisation (BSO) between April 2011 and October 2014. Health and Social Care Board (HSCB) practices operating within a capitation system were matched to a control group, who were remunerated using a retrospective fee-for-service system.ResultsNo evidence of patient selection was found in the HSCB practices set up by a corporate provider and operated under capitation. However, patients were less likely to visit the dentist and received less treatment when they did attend, compared to those belonging to the control group (P < 0.05). The extent of preventive activity offered and the patient payment charge revenue did not differ between the two practice groups.ConclusionAlthough remunerating NHS primary care dentists in newly set up corporate practices using a prospective capitation system managed costs within healthcare, there is evidence that this policy may have reduced access to care of registered patients.

A Novel Approach to Proactive Primary Care–Based Case Finding and Multidisciplinary Management of Falls, Syncope, and Dizziness in a One-Stop Service: Preliminary Results

National and international evidence and guidelines on falls prevention and management in community‐dwelling elderly adults recommend that falls services should be multifactorial and their interventions multicomponent. The way that individuals are identified as having had or being at risk of falls in order to take advantage of such services is far less clear. A novel multidisciplinary, multifactorial falls, syncope, and dizziness service model was designed with enhanced case ascertainment through proactive, primary care–based screening (of individual case notes of individuals aged ≥60) for individual fall risk factors. The service model identified 4,039 individuals, of whom 2,232 had significant gait and balance abnormalities according to senior physiotherapist assessment. Significant numbers of individuals with new diagnoses ranging from cognitive impairment to Parkinsons disease to urgent indications for a pacemaker were discovered. More than 600 individuals were found who were at high risk of osteoporosis according to World Health Association Fracture Risk Assessment Tool score, 179 with benign positional paroxysmal vertigo and 50 with atrial fibrillation. Through such screening and this approach, Comprehensive Geriatric Assessment Plus (Plus falls, syncope and dizziness expertise), unmet need was targeted on a scale far outside the numbers seen in clinical trials. Further work is needed to determine whether this approach translates into fewer falls and decreases in syncope and dizziness.

Another change agenda: Reflections on ‘Agenda for Change’

This article presents research on nurses’ perceptions of the 2005 UK NHS reform ‘Agenda for Change’ (AfC) in order to identify lessons to inform future NHS policy development. Semi-structured interviews (n = 18) were conducted with NHS nurses who were in post prior to the reform and subsequently subjected to the policy reform. Interviews were undertaken by a single researcher and lasted between 40–60 minutes. Interviews were recorded and transcribed verbatim and thematic analysis was used to identify key concepts and findings. The article finds that each facet of the Agenda for Change was not perceived to have achieved the policy goals it intended to. The article concludes that repeated political re-organisation of the National Health Service (NHS) in England has been demoralising for hospital staff.

Leadership in dentistry: findings from new tool to measure clinical leadership

Background In England, the recent reorganization of the National Health Service has led to the development of local dental networks and an emerging narrative on the importance of clinical leadership in dentistry. Analogous to clinical commissioning groups, local dental networks ensure general dental practitioners (GDPs) influence the delivery of local services. However, little is known about what GDPs think clinical leadership is and whether the construct has meaning. The aim of this study was to explore the structure of a pilot questionnaire to determine the qualities that GDPs deem are important and to use a data reduction methodology to produce a tool to measure clinical leadership. Methods A 61-item questionnaire was distributed to GDPs across the North West of England. GDPs were asked to rate the level of importance of each item using a 7-point Likert scale. Principal component analysis and direct oblimin rotation was used to examine for factor loadings within the questionnaire. Internal validity was tested by Cronbach’s alpha. Results Two principle factors emerged: “how to lead” and “how not to lead”. Individually, the item “I think it is important to have integrity” was rated as the most important. Conclusion The study developed a refined questionnaire that captures the important qualities of clinical leadership in dentistry. This is the first questionnaire that has been developed to capture important leadership attributes for GDPs.