Impact of Policy on Dental Health Needs

Policy Analytical Framework Dimension: Effects

1) Effectiveness: What effect does the policy have on the targeted health problem?

1.1) What is the objective of the policy (Maximum 100 words) [4 marks]

Nash et al. 2014

1. To address dental health problems & needs amongst children.

2. To provide a positive change in attitude towards dental therapist workforce.

3. To look at whether the dental care provided by trained & qualified dental therapists in non-clinical and clinical settings were effective, of quality and safe when compared to dental students and dentists in private practices

4. To look at the economic benefits to the population that received the care – mainly children.

5. To recognise dental therapists in providing direct access for basic dental care.

1.2) What is the proposed chain of actions that could produce the policy effects? Draw a proposed public policy logic model in the space below using text boxes. You should show (i) the public policy, (ii) the intermediate effects and (iii) the ultimate effects on the oral health problem [10 marks]. (No word limit)

1.3) What contextual factors have influenced the effectiveness of the policy in the UK and in the US? You should think about situational, structural, cultural and international factors (Maximum 200 words) [8 marks]

Buse et al. 2005

Situational

Following the adoption of the New Zealand model for employing dental therapists to treat specific dental needs in children, the UK/US dental governing body looked at how to adopt the same model amongst children in low socioeconomic communities and at the same time reduce dental caries and gum disease

Structural

The need to diversify the dental work force is in part due to the prevalence of associated disease such as diabetes and cardiovascular disease that are commonly associated with dental disease.

Cultural

Fierce opposition to the adoption of New Zealand model were seen amongst the dental profession because of the fears that dental therapists are not adequately trained to carry out basic dental treatment or perform dental treatment that is beyond their skillset when in remote areas where there are no dentists.

International

An attempt to legislate on the benefits of diversifying the dental workforce, thereby addressing the gaps between the dental inequalities amongst poor people. The fact that New Zealand was able to show a reduction in dental caries amongst children, meant that other countries could adopt the same principle, whilst appreciating the same economic benefit.

1.4) What evidence is there that the policy has produced intermediate and ultimate effects that have been sustained over time in the UK and in the US?  (Maximum 300 words) [10 marks]

Immediate Effect

The evidence shows that both the UK and US dental professional are having a change in attitude towards recognising dental therapist as an extended arm of the dental workforce that is not in competition with dentist, but a diversification of the dental service that dentist cannot provide. Secondly, there has been a reduction in dental caries amongst children, with an increase uptake in the application of topical fluoride. Likewise, the services have been welcomed within the local communities given its preventive approach. Freeman et al 2013.

Ultimate Effect

The ultimate effect of the policy to is to continue to provide a treatment template that will see a total reduction in non-communicable dental disease whether it is provided within a school setting, a community centre or in dental practices, and at the same time, remove the barriers to training dental therapist in order that they can continue to provide basic dental care to children.

2. Unintended Consequences

2.1) What unintended positive or negative effects has the policy produced? (Maximum 200 words) [8 marks]

The unintended consequence of this policy this in mitigating against the “simpler, more convenient, and less costly offerings initially designed to appeal to the low end of the market”

Christensen et al 2000.

Given the restricted pool of the students attending dental school, it worth noting that the pool of dental therapists is mostly from within the communities to the unserved population making it easier for the community to accept the services. Secondly, the community dental therapist pool helps to improve the language barrier amongst patients and the dental service provider. Dental therapists are salaried employees, this in turn helps to reduce the income difference when compared to those who work in private practice.

There is evidence to suggest better collaboration between dentist and the dental therapist, with dentists delegating more basic range of services, in spite of the opposition from the profession

Negative criticism of the dental therapist as a provider to basic dental service are largely seen amongst dentists who believe that the care provided are “second class … could endanger the health and safety of patients and public.” Jones G et al 2008

3. Equity

3.1) What effects has the policy produced in different groups in the UK and in the US? (Maximum 300 words) [8 marks]

The UK

1. The policy has helped to clarify the role of dental therapists compared to dentists when working in rural areas that are remote from the nearest dental practice or hospital

2. The policy has helped to recommend best practice within the dental profession, as radiological evaluations of clinical work done dentist and dental therapists were sometimes difficult to differentiate in quality.

3. Dental therapists are capable of treating not only poor children but vulnerable adults.

4. Dental therapists are capable of working independently especially in rural areas

5. Dental therapists are able to administer pain relief via local anaesthesia. This is particularly useful to the elderly who are house bound, and unable to travel long distance

The US

The creation of the dental therapist model in New Zealand, made it possible for the Alaska Dental Health board limited dentist to send therapists for training in New Zealand. After 3 years, the qualified therapist was employed back into the remote communities of Alaska. Conversely, in Minnesota, dentists were retiring early, thereby placing a heavy demand on the emergency service and increasing g the cost of treating dental disease. This led to the legislations that saw the introduction of new primary dental care and the certification of dental therapist to be the dental provider

Policy Analytical Framework Dimension: Implementation

4) Cost

4.1) What evidence is available to support the cost-effectiveness of the policy? (Maximum 200 words) [6 marks]

According to Beazoglou T J et al 2012, it depends on the supply of the dental care professional: dentist, dental therapist, dental hygienist and dental assistant versus the demand for the service in an open market. These authors were able to show that given the lower rate of reimbursement for children dental services to dentists, the same basic service can be delegated to a dental therapist, following a period of training. For this to happen several assumptions are made 1) they type of dental services to be provided, 2) what training skills are required, and 3) how the introduction of dental therapist will affect market conditions.

Using the supply and demand model, these authors showed that the introduction of dental therapists into the dental workforce only “affects the supply and not the demand for dental service.” The rationale behind this conclusion is that dentist is able to carry on delivering advance dental to patient whilst at the same time dental therapist could provide basic service such as administering local anaesthetics or taking radiographs, thereby making the production of dental service more cost-effective.

Other assumptions include: the capacity for the dental therapist to be competent in carrying out the service following a period of training and will only preform dental service that is within their clinical skills.

5) Feasibility

5.1) Who have been the important actors and stakeholders involved in implementing the policy (Maximum 100 words) [4 marks]

The important actors are:

Actors Stakeholders

Patients General Dental Council

Dental therapist National Health Service

Pilot practice owners/associate dentist British Dental Association

Universities/university researchers The Government

Oral Health Practitioner The Pew Charitable Trusts, the W.K. Kellogg Foundation, and the Rasmuson

Local commissioning group such as: the Yukon Kuskokwim Health Corporation Governing Body

 American Dental Association

5.2) What has been the main opposition affecting the implementation of the policy of using dental therapists in the UK and in the US? (Maximum 200 words) [6 marks]

The main opposition to implementation is in the UK is whether patients will accept dental therapists as substitute without the supervision of a dentist.  And in both the UK/US, is whether the dental care provided were effective, quality and safe.

However, given the fact that the dental workforce  is not enough to meet the needs of the population in both countries, and that dental therapist are trained not just to do basic treatment in children, but provide adult dental service such as fillings and extraction, the opposition have been largely refuted. Self et al. 2018. Though there still remain some concern about clarity of dental therapists who wishes to work in an NHS practice. Currently, there are no provision under the General Dental Service contract for Dental therapist.

6) Acceptability

6.1) What evidence is available to show that the actors have accepted the policy? (Maximum 100 words) [5 marks]

Patient satisfaction following a visit to the dental therapists is the predominant criteria for the acceptability of the policy. According to Sun N et al. 2010, a 10-item scale of patient satisfaction

questionnaire was analysed to compare visits to the dental therapist and dentist. The scale questioned patients about their overall satisfaction which included their experiences in how well they understood the information was being communicated, and how well was the treatment delivered. The report implied that 67.3% of completed questionnaires showed that patients were more satisfied with dental therapist than dentist. However, it is unclear about what, in particular, they were satisfied with.

Overall conclusions about the policy

Write a concluding statement reflecting on the overall strengths and weaknesses of the policy (maximum 300 words) [6 marks]

Historically, members of the WHO have looked into the prevalence of dental disease, in particular dental decay. To date, the problem persists in developed and developing countries.  In addition, dental disease has been linked to other systemic problems like Diabetes, Cardiovascular disease and HIV. Sadly, these diseases are mostly observed in disadvantaged people from low to middle income background. Given the limited resources in providing adequate care for everyone, key actors looked into ways of managing the available resources especially in remote rural areas in the UK and abroad.

One approach was to explore the New Zealand policy of training dental therapists to offset the workload of dentists by creating dental access for the underserved. The main strengths of this policy are benefits to patients, increasing the dental workforce and provision of a cost-effective service by dental therapists. The weakness of the policy in the UK is that dental therapists mainly serve in community clinics and private practices. The vast majority of dental practices in the UK with general dental service contract cannot employ a salaried therapist as there are no provision for reimbursement under the present unit of dental activity system.

In spite of the weaknesses of this policy, it is clear to see that patients especially children are the main benefactors. And school based dental initiatives that see dental therapists attending school to give oral health advise, apply topical fluoride, and carry out dental treatment have been largely welcomed by all actors. This is reflected in the fact that states within the US were willing to send representative to New Zealand for training. In the UK, the general dental council have given its’ support to dental therapists as a diversified group of the dental workforce. However, the GDC emphasized that dental therapists must only work within their clinical skill.

Citations

You should include in-text citations and a full list of references in this section using Harvard or Vancouver referencing style (see the QMPlus library resources page for further guidance: https://qmplus.qmul.ac.uk/mod/book/view.php?id=653429&chapterid=66189) [5 marks].

1. Beazoglou TJ, Lazar VF, Guay AH, Heffley DR and Balilit H. Dental Therapists in general dental practices: an economic evaluation. J. Dental Education (2012); 76;8:1082-1091

2. Buse K, Mays N and Walt G. Making Health Policy. Open University Press. First pub 2005, pp 11-14

3. Brikle CM and Self KD. Dental Therapists as New Oral health Practitioners: Increasing Access for Underserved Population. J Dental Edu. (2017); 81;9:eS65-eS72

4. Chi DL, Lenaker D, Mancl L, Dunbar M and Babb M. Dental Therapists linked to Improved dental outcomes for Alaska Native Communities in the Yukon-Kuskok Kwim Delta. J. Public Health Dentistry. (2018); 78:175-182

5. Christensen CM, Bohmer R and Kenagy J. Will Disruptive Innovation Cure Health care? Harvard Business Review. (2000); 78; 5:102-112

6. Edelstein B. Examining Whether Dental Therapists Constitute a Disruptive Innovation in US Dentistry. Am. J. Public Healtgh (2011); 101:1831-1835

7. Freeman R, Lush C, MacGillveray S, Themessl-Huber M and Richard D. Dental therapist/hygienist in remote-rural primary care: a structured review of effectiveness, efficiency, sustainability, acceptability and affordability. International Dental J. (2013); 63:103-112

8. Friedman JW and Mathu-Muju KP. Dental Therapists: Improving Access to Oral Health Care for Underserved Chdildren. American Journal of Public Health (2014); 104; 6 pp 1005-1009

9. Jones G, Evans C, Hunter L. A survey of the workload of dental therapists/hygienists-therapists employed in primary care settings. Br Dent J. 2008;204(3): E5.

10. Nash DA, Friedman JW, Mathu-Muju KR, Robinson PG, Satur J, Moffat S, Kardos R, Lo ECM, Wong AHH, Jaafar N, van den Heuvel J, Phantumvanit P, Chu E, Naidu R, Naidoo L, McKenzie I, and Fernando E. A Review of the global literature on dental therapists. Community Dent. Oral Epidermiol. (2014); 42:1-10

11. Sun N, Burnside G and Hasrris R. Patient satisfaction with care by dental therapist. British dental Journal (2010); 208; E9: 1-7

12. Self K, John MT, Prodduturu S, Kohil N, Naik A and Flynn P. Influence of Socioeconomic and Oral Health status on Acceptability of dental therapist’s Oral health Care. J. Health Care for the Poor and Underserved. (2018); 29; 3:1135-1152