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Background: Despite overall improvements in oral health, a large number of children in United Kingdom (UK) are affected by dental caries; and the implementation of oral health promotion in some families remains a challenge. As such, children from those families suffer high caries rates, and are frequently referred for tooth extraction under General Anaesthesia (GA), one of the commonest reasons for paediatric hospital admissions. The aim of this investigation is to explore referring primary care General Dental Practitioners' (GDPs) views and experiences in trying to promote better oral health for those children., Method: A qualitative study, utilizing face-to-face, semi-structured interviews with GDPs in three London boroughs who refer children for extraction of decayed teeth under GA selected based on referral rate. Qualitative Framework Analysis was used to present the results., Results: Eighteen GDPs (56% male) were interviewed: average age 42 years (range: 26-73 years). informants reported challenges to promotion of oral health categorised as: (1) child's young age, poor cooperation, and high treatment need; (2) parental skills to face up to modern day challenges and poor attitudes towards good oral health (3); social inequality, exclusion and cultural barriers in immigrant families; (4) National Health Services (NHS) primary care practice remuneration, constraints and training; (5) inadequate secondary care communication and engagement; and (6) failure in establishing national policy to grasp the width and depth of the problem., Conclusion: GDPs feel frustrated and isolated in their efforts to promote oral health in those children. These findings suggest difficult challenges on all fronts. Reform of preventive dentistry funding and delivery, as well as a multiagency multidimensional approach that is mindful of the social determinants of children's oral health and barriers to application of oral and wider health initiatives are needed to address this important public health issue.

Background: To determine the views of Clinical Directors working in the United Kingdom (U.K.) Cleft Service with regard to centralisation, commissioning and impact on cleft service provision., Methods: In-depth qualitative interviews were conducted with 11 Clinical Directors representing regional cleft services. Interviews were transcribed verbatim, a coding frame was developed by two researchers and transcripts were coded using a thematic, 'interpretive' approach., Results: Clinical Directors perceived the commissioning of cleft services in the U.K. to be dependent upon historical agreements and individual negotiation despite service centralisation. Furthermore, Clinical Directors perceived unfairness in the commissioning and funding of cleft services and reported inconsistencies in funding models and service costs that have implications for delivering an equitable cleft service with an effective Multidisciplinary Team., Conclusions: National Health Service (NHS) commissioning bodies can learn lessons from the centralisation of cleft care. Clinical Directors' accounts of their relationships with specialist commissioning bodies and their perspectives of funding cleft services may serve to increase parity and improve the commissioning of cleft services in the U.K.

On 12 June, General Dental Council Chair, Bill Moyes addressed the Faculty of General Dental Practice (UK) at its Malcolm Pendlebury lecture. Its contents have been subject to scrutiny, following the proposed substantial increase of the annual retention fee (ARF) and advertisements encouraging patient complaints. This article seeks to address concerns regarding the GDC's role and responsibilities.

UK NHS contracts mediate the relationship between dental and medical practitioners as independent contractors, and the state which reimburses them for their services to patients. There have been successive revisions of dental and medical contracts since the 1990s alongside a change in the levels of professional dominance and accountability. Unintended consequences of the 2006 dental contract have led to plans for further reform. We set out to identify the factors which facilitate and hinder the use of contracts in this area. Previous reviews of theory have been narrative, and based on macro-theory arising from various disciplines such as economics, sociology and political science. This paper presents a systematic review and aggregative synthesis of the theories of contracting for publicly funded health care. A logic map conveys internal pathways linking competition for contracts to opportunism. We identify that whilst practitioners' responses to contract rules is a result of micro-level bargaining clarifying patients' and providers' interests, responses are also influenced by relationships with commissioners and wider personal, professional and political networks., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Unlabelled: This article looks at the background to the current changes in primary care dentistry being piloted in England. It looks at the structure of the different elements being piloted, such as the oral health assessment, interim care appointments and care pathways. It also examines advanced care pathways and how complex care will be provided when clinically feasible and beneficial to the patient. The authors have worked in a type 1 pilot practice since September 2010., Clinical Relevance: The NHS contract currently being piloted in England delivers care through care pathways and clinical risk assessments with prevention as an important building block for the delivery of services. There are new measures planned for measuring quality outcomes in primary care. This has implications for how services are delivered, who delivers them and how dentists will be remunerated in the future.

Conscious sedation is an integral part of modern day dental care and should be delivered through a high quality, effective and evidence-based approach. Commissioning of NHS dental services in England is currently under review by NHS England and the National Dental Commissioning Group. This group has identified the management of vulnerable people including anxious patients, as one of its priorities. The Society for the Advancement of Anaesthesia in Dentistry (SAAD) believes this provides an opportunity to influence the commissioning of NHS conscious sedation services. With this aim in mind,"Guidance for Commissioning NHS England Dental Conscious Sedation Services: A Framework Tool" was developed. This guidance proposes a common approach to the organisation of NHS dental conscious sedation services in England, advocating the provision of Tier 1 and Tier 2 services in all regions. Its ethos is a"hub and spoke" model of service delivery with patient assessment delivered by experienced and well trained dental sedationists at its core. In line with the recent Francis Report fundamental standards for all aspects of dental conscious sedation practice are outlined, supported by a robust and predictable quality assurance process. This work has been shared with key stakeholders in NHS England including the Chief Dental Officer and the Head of Primary Care Commissioning.

Background: Role-substitution describes a model of dental care where Dental Care Professionals (DCPs) provide some of the clinical activity previously undertaken by General Dental Practitioners. This has the potential to increase technical efficiency, the capacity to care and reduce costs. Technical efficiency is defined as the production of the maximum amount of output from a given amount of input so that the service operates at the production frontier i.e. optimal level of productivity. Academic research into technical efficiency is becoming increasingly utilised in health care, although no studies have investigated the efficiency of NHS dentistry or role-substitution in high-street dental practices. The aim of this study is to examine the barriers and enablers that exist for role-substitution in general dental practices in the NHS and to determine the most technically efficient model for role-substitution., Methods/design: A screening questionnaire will be sent to DCPs to determine the type and location of role-substitutive models employed in NHS dental practices in the United Kingdom (UK). Semi-structured interviews will then be conducted with practice owners, DCPs and patients at selected sites identified by the questionnaire. Detail will be recorded about the organisational structure of the dental team, the number of NHS hours worked and the clinical activity undertaken. The interviews will continue until saturation and will record the views and attitudes of the members of the dental team. Final numbers of interviews will be determined by saturation.The second work-stream will examine the technical efficiency of the selected practices using Data Envelopment Analysis and Stochastic Frontier Modeling. The former is a non-parametric technique and is considered to be a highly flexible approach for applied health applications. The latter is parametric and is based on frontier regression models that estimate a conventional cost function., Discussion: Maximising health for a given level and mix of resources is an ethical imperative for health service planners. This study will determine the technical efficiency of role-substitution and so address one of the key recommendations of the Independent Review of NHS dentistry in England.

Changes in commissioning and contracting of NHS dental services will impact on oral healthcare delivery, providing new challenges and opportunities for children's oral healthcare. Now is the time to assess clinical networks and specialised services to understand how the oral healthcare needs of all children can be met appropriately and effectively so that when change comes it can be embraced for the better.

Objectives: Current UK and US economic conditions have re-focussed attention on the need to deliver dental care with limited finance and resources. This raises hard questions determining which services will be offered and what they should achieve to satisfy public demands and needs. We consider impending dental health reforms in the US and UK within the context of contemporary experiences to identify issues and delivery goals for the two nations., Background: The paper provides a brief history and background of the development of social dental care models in the UK and US, highlighting some differences in state-funded delivery of dental care. SHIFTING DEMAND: From the 1950s, demand for dental treatment has increased and acquired a more complex composition growing from predominantly surgical and restorative treatment to encompass preventive care and cosmetic services. PRIORITISING CARE ACCORDING TO NEED: Despite improvements in general health and technology, inequalities in access and utilisation of dental care are still experienced, primarily by groups with low socio-economic status. DELIVERY: BALANCING RESOURCES, DEMAND AND NEED: In developing and delivering reform agendas, much can be learned from previous policy interventions. Pressures of cost, coverage, and capacity, besides demand versus need must be carefully considered and balanced to deliver quality service and value for users and taxpayers., Conclusions: Ethical and moral consideration should be given to making services needs-driven to address high treatment requirements rather than the high care demands of the worried well. This challenge brings the additional political pressure of convincing many of the voters (and subsequent complainers) that their demands may be less important than the needs of others.

An analysis of annual reports revealed that on average 20% of patient appointments with oral hygienists in the Department of Health in the Pretoria region were not utilised due to patient noncompliance (i.e. broken appointments). Many solutions have been considered to address the high rate of noncompliance and the resulting idle chair capacity. One solution selected to overcome some of the negative consequences of broken appointments was deliberate overbooking. The aim of our study was to determine the effect of overbooking on idle dental chair capacity by measuring the utilisation rate over a three month period (July to September) after 25% overbooking was introduced in the Pretoria region. A statistical analysis was conducted on our results to determine an overbooking rate that would ensure full utilisation of the available dental chair capacity. The available time units over the three month study period amounted to 1365, allocated to 1427 patients resulting in an overal overbooking rate of 4.54%. The overall utilisation rate was found to be 79.2%. The calculated regression line estimated that there would be full utilisation of dental chair capacity at an overbooking rate of 26.7%. Overbooking at the levels applied in this study had a minimal overall effect on idle dental chair capacity. Our results confirm the need for careful planning and management in addressing noncompliance. In a manner similar to the clinical situation, organisational development requires a correct diagnosis in order that an appropriate and effective intervention may be designed.

This paper describes the complex Greek health insurance system in 2011 and how it funds some aspects of oral health care for the population. It explains how different aspects of oral health care for different groups in Greek society are funded by insurance schemes or the national health system (ESY) or purely by direct (out-of-pocket) payments from patients to dentists. It then describes the Greek oral health care workforce and explains that relative to the population there are more dentists than in any other European country. However, few work with chair-side assistance from dental nurses and there are no dental hygienists. There are two dental schools, whose intake may well be reduced in the near future. There are also only two recognised dental specialties (orthodontics and oral surgery). Some epidemiological data and costs are then presented. The paper finishes with a consideration of problems in oral health care in Greece and suggests how some may be overcome.

Aim: To describe the establishment of a referral only oral surgery service in a primary care setting together with the challenges, benefits and successes of the service., Problem: In 1994 waiting times for hospital for oral surgery and maxillofacial procedures were unacceptably long. A proposal to establish a primary care oral surgery service aimed to complement the hospital-based service, reduce treatment delays., Outcome: Referrals commenced immediately in response to a managed launch with local dentists recognising the service as a source of expedient and convenient treatment for their patients. The service now treats up to 1300 patients per year., Learning Points: New dental services to dentistry can encompass different specialities. Initial capital investment is needed to develop a more cost-effective service. Recruitment of suitable specialist staff is a critical for success. Staffing, organisation and funding must be sustained.

Aim: To detail orthodontic provision in Wales., Background: In 2006 the new orthodontic contract was introduced in the NHS in England and Wales. Since the introduction of the new contract there have been recent reports of inefficiencies in orthodontic provision in Wales in terms of: orthodontic provision reaching those who need it, type of orthodontic activities undertaken, who is providing orthodontic care, the relative cost-efficiency of the orthodontic services, contracting and performance management of the services and robustness of the orthodontic database., Materials and Methods: 2008/09 orthodontic data on contracted services were analysed. Data from the salaried services was collected through a questionnaire. Normative orthodontic treatment need was estimated from mid-year population estimates., Results: In 2008/09, there were considerable inefficiencies in the orthodontic services in Wales with varied level of access by children living in 22 former local health boards, co-terminus with local authorities in Wales. Total spend on orthodontics in Wales was around £12,718,370. It was estimated that 11,539 (30%) of 12-17-year-olds required orthodontic treatment. In 2008/09, 11,031 children received orthodontic treatment in all NHS services in Wales indicating a potential shortfall of 508 treatments. Out of 135 GDS/PDS orthodontic contracts, 27 provided no active treatment (only assessments) and 62 provided less than 50 treatments annually. Cost per units of orthodontic activity (UOA) ranged from £58 to £74. With improved contracts and efficiency, the orthodontic budget seems sufficient to meet the orthodontic need of the population., Conclusions: As with any type of NHS provision, it is important that orthodontic services are competitive, highly efficient and provided on the basis of need. Performance management of orthodontic services should focus on the number of successful orthodontic treatments delivered annually. The personal dental services (PDS) orthodontic contract will need to be modified accordingly.

Between the end of 2009 and 2010, the General Dental Council (GDC) changed and the part appointed, part elected body which had been in place since its inception in 1957 became fully appointed. Since then, various quite radical departures in terms of its committee structure and proposals for the education and training of dental professionals have emerged. This paper reviews these developments in the wider context of the Council's role, recent record and overall accountability.

The Modernising Medical Careers framework provides the opportunity for both medical specialists and general medical practitioners to follow training pathways that lead to appointments as National Health Service (NHS) consultants and to senior academic posts. Similar opportunities are available for dentists who wish to specialise. However, they are not available to dentists working in primary dental care who wish to become NHS consultants or senior academics in general dentistry. An alternative pathway is required that does not force committed primary care dentists who wish to become NHS consultants or senior academics down a path of specialisation. In this paper, the authors explore the situation in some detail and propose a career pathway with appropriate competencies for primary care dentists who aspire to become NHS consultants or senior academics. They justify why such posts should be created. The competencies have been developed using key guidelines and documents from the European Bologna Process and the Association for Dental Education in Europe, the Curriculum for UK Dental Foundation Programme Training, and the General Dental Council monospecialty curricula. It is hoped that the proposed pathway will produce highly trained generalists who will: (a) encourage and undertake research in primary dental care, where over 90% of dentistry is delivered, (b) support and lead outreach centres so that teaching and clinical cases reflect primary dental care, where students will spend their working lives post-qualification, and (c) provide a means of increasing the numbers of clinical dental academics, which have been in decline over the last 10 years.

The Department of Health's response to the national budget deficit is to ensure that the provision of NHS services is guided by four fundamental 'QIPP' principles: Quality, Innovation, Prevention, and Productivity. This agenda will govern all aspects of the National Health Service's (NHS') health care provision for the foreseeable future. NHS dental services will, like all other NHS services, need to make a contribution to the QIPP agenda. The purpose of this paper is to outline the implications for NHS dentistry.

Introduction: Retaining and Returning Advisers (RRAs) were appointed to postgraduate dental deaneries in England in 2002 as part of the Government's strategy to retain the dental workforce and support return to practice following a career break. The study aimed to review RRAs' activities and consider the overall success of the RRA initiative five years from inception (2007)., Design and Methods: A case study design, conducted in three phases, drawing on qualitative data. In Phase 1, semi-structured interviews were held with all RRAs in England (n=12). Phase 2 involved an electronic survey of all 12 postgraduate dental deans in England (n=10). In Phase 3, analysis was undertaken and a final report prepared., Results: RRAs have been flexible in responding to the changing policy context, and devolved funding for the role to the local, deanery level. They have adapted to support more diverse target groups including those seeking vocational training equivalence and underperforming dentists. Future priorities were envisaged to be associated with primary care trusts' commissioning and quality assurance responsibilities, and supporting all members of the dental team., Conclusion: RRAs have become well-established in deaneries and have made a successful contribution to addressing workforce and educational needs for a diverse group of practitioners.

The development of leadership in healthcare has been seen as important in recent years, particularly at the clinical level. There have been various specific initiatives focusing on the development of leadership for doctors, nurses and other health care professions: for example, a leadership competency framework for doctors, the LEO programme and the RCN clinical leadership programme for nurses. The NHS has set up a Leadership Council to coordinate further developments. However, there has not been the same focus in dentistry, although the recent review of NHS dental services (Steele review) has proposed a need for leadership initiatives in NHS dentistry as a medium-term action. Central to this will be a need to focus on the leadership role for dental surgeons. Leadership is all the more important in dentistry, given the change of government and the policy of retrenchment, major public sector reform, the emergence of new organisations such as new commissioning consortia, possible changes to the dental contract, new ways of working, and changes to the profession such as the requirements for the revalidation of dental surgeons. The question is: which leadership theory or approach is best for dental surgeons working in primary care? This paper builds on earlier work exploring this question in relation to doctors generally, and GPs, in particular, and planned work on nurses. It will seek to address this question in relation to dental surgeons working in primary care.

Recent changes to the system of remuneration and contracting arrangements with Primary Care Trusts (PCTs) has meant that dental practitioners in the UK have experienced several types of incentive and governance arrangements. This paper uses data from a qualitative study of 20 dental practitioners to examine the influence of different systems of incentives and governance on their motivational system. Results show that a perceived reduction in autonomy was the least acceptable aspect of the health reforms. The study also suggests that conflict between self-interested and altruistic motives may occur where medical professionals operate as independent contractors in a small business environment. Whilst dentists appeared to show altruistic motives towards their patients, priorities towards running an autonomous business enterprise meant that PCT managerial requirements, for example, to widen access were not welcomed, because of their impact on managerial autonomy. Moreover, whilst dentists' professional ethos appeared geared towards achieving technically high quality standards of work, this produced tensions against a background of cost containment in a fee-per-item system of remuneration. The paper raises issues such as the person-system interaction associated with professional and individual autonomy and the importance of reciprocity and fair payment., (Copyright © 2010 John Wiley & Sons, Ltd.)

The government changed the system of payment to general dental practitioners on 1 April 2005 from a fee/item to a banding system. The figures collected have shown that there has been a 62% increase in the number of patients who require admission for surgical treatment of spreading odontogenic infections compared with the 3-year period before this date., (Copyright © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)