Summary of: Managing resources in NHS dentistry: the views of decision-makers in primary care organisations

Key Points

• Explores the views of dental decision-makers about resource allocation in NHS dentistry.

• Describes the demand for local dental data to inform commissioning processes.

• NHS dental care providers could be more involved in local decision-making and commissioning processes.

• Highlights the need for decision-makers to ensure that finite resources maximise the oral health of local populations.

Abstract

Objective To investigate priority setting and decision-making in primary care organisations and to determine how resources are managed in order to meet the oral health needs of local populations.

Method This is a qualitative study. The purposive sample comprised twelve dental public health consultants and six senior finance representatives from contrasting care systems across the United Kingdom. Participants completed a written information sheet followed by a recorded semi-structured telephone interview. Conversations were professionally transcribed verbatim and analysed independently by two investigators using the constant comparative method.

Results The emergent themes focused upon: the role of participants in decision-making; professional relationships; managing change; information needs; and identifying and managing priorities. There was wide interpretation with respect to participants' roles and perceived information needs for decision-making and commissioning. A unifying factor was the importance placed by participants upon trust and the influence of individuals on the success of relationships forged between primary care organisations and general dental practitioners.

Conclusion To facilitate decision-making in primary care organisations, commissioners and managers could engage further with practitioners and incorporate them into commissioning and resource allocation processes. Greater clarity is required regarding the role of dental public health consultants within primary care organisations and commissioning decisions.

Main

R. D. Holmes, C. Donaldson, C. Exley and J. G. Steele British Dental Journal 2008; 205: E11

Editor's summary

This paper is an interesting addition to the increasing body of research into the situation in NHS dentistry following the introduction of the new dental contract in England and Wales. The paper focuses on the views and experiences of some of those working for the primary care organisations (PCOs) responsible for commissioning dental services under the new contract, information which is vital in order to ensure that future commissioning and decision-making strategies in NHS dentistry come from the most informed position possible.

The authors interviewed consultants in dental public health and senior finance representatives from 12 contrasting PCOs across the UK. Unsurprisingly given the time that the study was undertaken, the views of the consultants and the finance representatives were at times quite different, particularly when they considered their roles within the PCOs: there appeared to be no clear consensus as to the consultants' roles in decision-making and commissioning, and they often reported feeling unstable and uncertain in their jobs, whereas finance representatives were able to clearly define their roles and positions within their PCOs.

The authors point out that the study represents a 'snapshot in time' that was taken during a period when NHS dentistry was experiencing great change. While some of the findings reflect this upheaval and will hopefully be temporary, the wider issues that are raised will remain pertinent in the future, particularly the importance of developing professional relationships between general dental practitioners and primary care organisations, and how best to allocate scarce resources at local levels. The three key action points recommended in the conclusions of the paper could help to overcome some of the problems highlighted by the study participants. It is to be hoped that papers such as this will stimulate those involved with the commissioning of primary care dental services, both nationally and locally, to begin to implement these actions in the near future.

The full paper can be accessed from the BDJ website ( http://www.bdj.co.uk ), under 'Research' in the table of contents for Volume 205 issue 6.

Rowena Milan, Journal Editor

Author questions and answers

1. Why did you undertake this research?

Healthcare managers should have no more important activity than that of setting priorities and allocating resources.¹ These responsibilities are particularly relevant to those operating under the new dental contract, where primary care organisations (PCOs) have been charged with meeting the oral health needs of local populations with scarce resources. The study explores decision-makers' views on the provision of local dental services in England and includes those operating under contrasting dental care systems in other areas of the United Kingdom.

2. What would you like to do next in this area to follow on from this work?

The next phase of the research will see the application of a pragmatic economics-based framework within several primary care trusts to determine its ability to guide and assist decision-makers in their priority setting and commissioning responsibilities. The framework will incorporate stakeholders in an inclusive approach to local priority setting and resource allocation. Ultimately, the framework may assist with the efficient and equitable distribution of scarce dental resources while developing dental commissioning within the PCTs concerned. The research will also build upon some of the constraints imposed by oral health needs assessments, which do not provide answers to fundamental questions including how many resources should be re-allocated to meet identified shortfalls in service provision.

Comment

The introduction of the new contract in April 2006 in England and Wales changed the way dentistry in the NHS at primary care level is supplied. The changes forced primary care organisations (PCOs) to take responsibility for the provision of services to the general public and not solely to the patient groups unsuitable for treatment in general practice as in the past.

This was a completely new experience for PCOs and this paper seeks to determine how well some of them have coped with this responsibility. To this end the authors questioned some consultants in dental public health and some finance managers in various PCOs from areas differing geographically and socially and including Scotland and Northern Ireland, which do not have the new contract.

It is widely recognised that the expertise of PCTs differs markedly, but what emerged from the research was that the functions of the consultants in dental public health varied widely; seemingly dependent on the whims of the particular PCO. There exists no specific job description of what such an expert is required to do or what advice should be provided. One should be surprised, but given the unseemly haste with which this new contract was introduced this appears to be another area where no clarity of purpose is evident.

At the time the research was carried out (October 2006-February 2007) there seem to have been several of the selected PCOs that had vacant senior finance officer posts.

Consultants had the view that their services and expertise were not valued, being considered an expensive indulgence in light of the small proportion of the PCT budget allotted to dentistry.

Priority setting is an essential part of managing finite resources but there was little evidence that a balanced approach was taken. Quite often it was a single issue which determined expenditure. There was little evidence that local GDPs were involved in commissioning processes.

Inevitably, there will be some tension between the interests of the consultants and those of finance personnel. The ending of the three year income guarantee period in 2009 may well illustrate those differing priorities.