Planning a dental workforce for the future for the National Health Service in the United Kingdom: What factors should be accounted for?

People expressing their demand for clinical care

A common misconception within workforce planning is that demand is equivalent to population need. The two methods used in the last Primary Care Dental Workforce Review ⁵ both took current provision at face value rather than examining population need in more detail. Whilst health is defined as ‘a state of complete physical, psychological, and social wellbeing and not simply the absence of disease or infirmity’ ⁸ , there is an analytical difference between ‘actual need’, ‘felt needs’ described as ‘wants’ and expressed needs described as ‘demands’ ⁹ . The latter two are predicated on good health literacy ¹¹ ; that is, an understanding of the consequences of leaving needs unmet and what care is available. Demands also influence expectations about the types of care that should be received and, in the latest review of NHS dentistry, Steele argues that some of these expectations may require substantial readjustment to align demand with need ⁶ .

Demands are also influenced by the suppliers of care and this is known as ‘supplier-induced demand’. This argues that the mere presence of a service is enough to create demand in addition to activities from the suppliers to sell particular services and treatments. Within dentistry, there is evidence that suppliers generate demand from their patients to ensure continued profitability ¹² and that contractual arrangements can have a significant impact on the types of treatment delivered. As the vast majority of the costs for NHS dentistry are spent predominantly on routine care for patients who regularly attend, without substantial treatment need, the potential for the current emphasis on demand for care has the potential to perpetuate the health inequalities in the system ^12–14. A service that does not account for and address these issues will not ameliorate the inverse care law ¹⁵ .

The key to this is to understand ‘valued need’ across the different socio-economic, cultural and ethnic groups, particularly given the substantial changes that are occurring as a result of net migration. In addition, it also requires an appreciation of the improving oral health of the nation and the cohort effect caused by increased accessibility to fluoride and advances in restorative dentistry ¹⁰ . Exchange theory suggests there is a trade-off between the cost of an item and the value that an individual places on it ¹⁶ . One of the problems that the dental profession and policy makers are ethically bound to address is: how does it reduce the expectations and demand from those patients that do not require it, whilst ensuring it tackles those at most need, when this need is not valued?

Given this market segmentation, there is a need to state the desired outcome for these different social groups a priori and then determine how this can best be delivered. However, to date, there has been a dearth of high-quality research examining the most efficient means of delivering such benefits in general dental practice. Instead, services have developed historically based on the ability and ‘willingness to pay’ of individuals in the context of the local availability of services. Within the NHS current demand is filtered through a fee structure, which is represented by the dotted red line in Figure 1. Therefore, there remains an opportunity to screen out inappropriate demand, should there be a will to do so from either the government or the profession.

Clinical health workforce

Masnick and McDonnell argue that the supply of services from the workforce is related to a number of factors: number of clinicians, skill mix, retention of personnel, worker time pressures, skills gap effects on productivity and appropriate deployment.

The principle input into the clinical workforce in NHS dentistry stems from graduates from dental schools across the United Kingdom (UK) entering employment into the service after appropriate training. This is supplemented by the return of clinicians who hitherto were outside the system, in addition to migration of dentists from different countries. Those leaving the system include those who decide to retire, or who die while in employment, along with clinicians who no longer wish to work within the system or who decide to take a temporary break from working.

With the growing feminization of the workforce, there appears to be potential for considerable variance in both the net flow of clinicians into and out of the system and the range of different working practices adopted. In a recent survey, only half of female dentists envisaged working full time, which was significantly different to male dentists ¹⁷ . Achieving a satisfactory ‘work-life balance’ was rated as important along with the availability of childcare for future working capacity ¹⁷ .

These findings are also consistent with the work of Stewart et al. ¹⁹ who examined the perspective of dental graduates. They found that one quarter of females intend to work part time. Stewart et al. also found that, across both male and females, only 3 per cent intended to work exclusively for the NHS, and more than half of the sample intended to take time out of dentistry ¹⁸ . This pattern of personal values influencing working patterns was found by Gallagher et al, where a favourable work–life balance was again critical amongst newly-qualified Vocational Dental Practitioners (VDPs) ¹⁹ . A further paper by the same research team found that working within the NHS was only attractive to VDPs who valued its ethos, although working within the NHS could be enhanced by incentives and increasing the degree of fit with their personal aspirations ²⁰ .

In Wales, only 10 per cent of VDPs who saw their future in general dental practice indicated an aspiration to work in the NHS, with the vast majority (93.6 per cent) being concerned about restrictions to where they could practice under the NHS arrangements ²¹ . Again, family and other social commitments were a significant influence, and over three-quarters of the sample suggested that they would be working part-time in the future, and that private dentistry was an attractive alternative to NHS dentistry ²¹ . This highlights the tension between planning for a state-funded system that exists alongside a free-market economy.

Ethnicization of the dental workforce is another variable to consider, although its impact is unclear at this stage. In one of the few studies that have examined this area, Newton and Gibbons found that there has been a steady increase in the number of minority ethnic groups amongst recent graduates ²² , whilst Bedi and Gilthorpe found that over one third of all students applying to medicine and dentistry were from minority ethnic groups, with the latter profession being preferred (OR = 1.83, 95 per cent CI = 1.73,1.94) ²³ . Social position from a ‘respected’ profession and the ability to work with others who share similar beliefs were found to be important ²⁴ . More importantly, for workforce planning, there appears to be some evidence that these groups are more likely to treat patients within the NHS ²² , although more work is required in this area to properly examine the possible effect of the changing ethnic profile of the profession in the United Kingdom.

The 2006 contract has also seen a net outflow from the NHS as a result of professional dissatisfaction ²⁵ . Financial incentives within the remuneration structures therefore plays an important part to the future shape of the NHS and influences workforce behaviour and the types of treatment provided. However, since the Bologna declaration, 29 European Union countries have pledged to reform their training structures to facilitate greater homogenization and movement of health professionals across Europe ²⁶ .

The supply of services into the NHS workforce is therefore dependent on a number of factors that impact on the net flow of numbers of practitioners in the system. However, demographic approaches also make the assumption that productivity is constant across a practitioner’s lifetime and that there are no skill gaps created by the movement of labour into and out of the system.

The provision of supply can also be influenced by the division of labour in the clinical workforce. The use of skill mix in dentistry across the developed countries appears to increase in regions where there is a shortage of supply of dentists, and where there has been increased population need ²⁷ . However, ‘team working’ is an area where the dental profession has lagged behind their medical colleagues ²⁸ . In medicine, nurses or auxiliary staff can either supplement or substitute the services provided by doctors, depending on their skill base and legislated scope of practice ²⁹ . The former is a term to describe how nurses provide services which are in addition to, and complement or extend, those services provided by doctors, whilst the latter is where services previously provided by doctors are undertaken by nurses. The former is likely to increase health service costs; the latter is likely to reduce them. These terms are important conceptually as they identify the role to be played by an individual and the impact this has on the economic viability of the model used. However, there is evidence in the literature that attempts at substitution often end up with the auxillary supplementing the service, leading to service enhancement rather than supplementation due to prevailing attitudes within the workplace ³⁰ . Despite this, there has been a recent resurgence in interest in the use of skill-mix since the publication of the NHS review^11,31and there is some evidence of its social acceptability amongst patients ^32–34. However, there remains uncertainty amongst the profession about their potential roles ³⁵ . Overall, financial considerations appear to play a significant part in the decision to use a therapist ^36–41, with their cost-effectiveness being marginal at best, from a practice perspective^42–44. Knowledge of their scope of practice, perceptions about patient acceptance, and the need for adequate management and supervision have also been identified as further barriers^{36–38,41,42,44–48}. In addition, there has been a degree of reported negativity towards their employment in general dental practice^49,50, which has been attributed to the threat that the dually qualified hygiene-therapists pose to the profession^41,50,51.

A more complete understanding of the dynamics of supply also require an understanding of the ‘funds and support’ as alluded to earlier, including funding and the political support relevant to the clinical professionals’ ability to provide clinical care. The legislative environment for dentistry in the NHS in the UK and the financial incentives that are produced appear critical for the future of role substitution and workforce more generally. The latter is important given that general dental practitioners (GDPs) own their premises and so are driven to run their practices as businesses to off-set the cost of their capital investment in equipment and premises, whilst ensuring liquidity to cover their overheads ⁵² . The structure of the 2006 contract caused a dramatic shift in the prescribing patterns of GDPs ⁵² due to the change in the financial incentives compared to the fee-per-item contract ⁵³ . This caused a marked drop in the number of complex treatments undertaken, whilst the number of extractions rose after 2006 (Figure 2) ⁵³ . Given this, the viability of role-substitution has yet again been called into question ⁵⁴ and many therapists are currently being employed as hygienists rather than being utilized across their full range of their skills. ⁵⁵

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Figure 2.

Changes in prescribing patterns after the introduction of the new contract in 2006 ⁵³

Masnick and McDonnell’s tool terms this complex interaction between healthcare professionals along with the relationship between the profession and the patient the ‘clinical care microsystem’ ³ . As highlighted in this paper, it is a complex socio-technical system ⁵⁶ , which can be either constrained or enabled by the structural environment ⁵⁷ . As Masnick and McDonnell argue, ‘the effectiveness and efficiency of [service provision] reflect the productivity and quality of work’ within “Clinical Care Microsystems” ³ . In dentistry, this is complicated further by the large capital assets held outside of the system ⁵² , with the majority of dental practices being owned by general dental practitioners. This has eliminated the financial risk for the NHS, but at a cost, as there is no control over services being lost to the system. Consequently there are fewer levers that can be used to facilitate change, as dentists working within the system can simply move their services out of the NHS, should this be feasible ¹⁰ .

The final component that Masnick and McDonnell introduce is the social structure that healthcare is embedded within, including the social determinants of health ⁴ . This builds on the framework of Evans et al ⁵⁸ for representing the dynamics of health, which link healthcare values to the rest of the social institutional structures that affect citizens.

Medical technology

Changes in medical technology can have a profound impact on the modelling process^1,3,4. In dentistry, it is well recognized that the introduction of fluoridated toothpaste and the air-rotor produced cohort effects, which was highlighted by Steele in his review of NHS Dentistry ¹⁰ . As a result, three distinct groups of patients with very different needs are evident at a population level: those with little exposure to disease, those who are predominantly edentulous and, finally, those termed the ‘heavy metal generation’ who are stuck in a perpetual restorative cycle. It is difficult to predict what the future holds for dentistry, but taking a demographic approach to workforce planning that does not account for the impact of this cohort effect is likely to lead to an oversupply within the system as the trend towards improving population health continues. Advances in primary, secondary and tertiary prevention alongside more efficient management of the common dental diseases will continue to impact on this relationship in the future.

Similarly, advances in the evidence base for care may demonstrate that, currently, prescribed treatments do not offer any health benefit and could be decommissioned.