Fiona Ellwood looks closely at what 'skill mix' means for dental nurses, as shared with members of the Society of British Dental Nurses (SBDN).

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In January this year the Office of the Chief Dental Officer/NHS England published welcome guidance on 'skill mix'.1 Skill mix has been a topical conversation for many years; in some areas it has been adopted and in others, it has not. If we look at the literature over the years, it has been identified as both 'skill mix' and also 'role substitution'.

Role substitution is well established in a number of other countries2 and in 2013 when direct access was introduced3 the door opened to allow role substitution to become part of the wider workforce commitment. Dental therapists and dental hygienists were able to see patients without the dentist having to see them first, but only on a private basis, in general practice in the first instance. Dental nurses were able to undertake direct access work as part of a structured programme to provide public health interventions.4 Currently, they cannot work under a patient group direction (PGD)5 and this needs to change. Neither must the orthodontic therapists and the clinical dental technicians be forgotten when it comes to direct access. The earlier work of Brocklehurst and Tickle6 set the context for skill mix, as did the earlier work of the late Professor Jimmy Steele.7 This mantra has also been addressed by Professor Gallagher8 and others along the way.

What has already been said

There is a commitment towards workforce planning and in support of skill mix, there is an aspiration from the Society of British Dental Nurses (SBDN), to see the whole team - including dental nurses - being able to work to their full scope of practice and to see a re-modelling of the prevention team. I believe that dental nurses are well-placed to deliver preventative messages and oral health support as part of the prevention and intervention strategy. I strongly believe that dental nurses are underutilised in this capacity and that it will give them more job satisfaction and play a role in retention.

There is some way to go on this work and the Society has asked a number of questions of the regulator and awaits a response. The Society has in particular asked for absolute clarity on who can do what and who can ask what of whom. This is essential on a number of fronts, as dentists are identified as the main professional group who are recorded as prescribing to dental nurses for particular components of patient care. If dental therapists and dental hygienists are to now replace the dentist by making the requests, now that they can now open a course of treatment, this has to be made clear. In addition to this, dentists are often the clinical supervisors for dental nurses in training; it is important to be clear on all fronts that the dental therapist or dental hygienist will have the capacity to do this too and in the same context. This is not questioning their ability, capacity or capability, it is about time and training provider guidance and the provision of a full range of skills, in order to allow student dental nurses to gain experience in a broad range of clinical activities.

Dental nurses are adaptable, flexible, and able to manage change and nothing has shown this more than the pandemic. We are truly hopeful that words will become actions, as we work together to make a difference.

The dental therapist and the dental hygienist opening up a course of treatment is more likely to need a dental nurse working with them, as suggested in the General Dental Council's Standards for the dental team.9 Currently, this still seems to be a luxury and perhaps even a challenge with current workforce issues. The Society welcomes the changes and looks forward to what this means for dental nursing, but we recognise this is unfinished business. It is time to implement an optimisation strategy and to take a systems approach to what has been identified as a 'wicked problem'10 going forwards if this is to serve patients as it is intended to.

The Society sees this as an opportunity to work collaboratively and explore what could be done, not what cannot. We believe that if everyone is looking outside the box then perhaps it is time to look inside it again and do what we do best, for the right reasons and with the right outcomes to provide the right services to the right people. Dental nurses are after all adaptable, flexible, and able to manage change and nothing has shown this more than the pandemic. We are truly hopeful that words will become actions, as we work together to make a difference.