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M. Al-Haboubi S. Eliyas P. F. A. Briggs E. Jones R. R. Rayan and J. E. Gallagher British Dental Journal 2014; 217: E6

Editor's summary

Planning service provision is probably one of the least likely reasons that anyone would give as their motivation to apply for dentistry as a career. This is not surprising given that it suggests a somewhat dry subject area with very little of the hands-on or wet-fingered activity that we as dentists love.

Yet without such organisation the appropriate treatment may not be available for delivery to patients who require it and the relevantly competent clinicians may not be on hand to provide it. Matching demand and supply is probably more difficult in dental care than in any other walk of life. Classically the balancing act is bedevilled on one side by the relatively fickle nature of patient choice; as to whether they attend the dentist at all, only when in pain or on a regular basis, and then to make choices based on personal circumstances including other priorities, such perception of health, degree of commitment and finance.

Simultaneously, on the supply side, the calculations have to be made, or perhaps guessed at, years in advance to gauge dental school entry numbers, postgraduate training, specialist career pathways plus the trade-off between full-time and part-time practitioners, female to male ratios and other personal considerations.

Against this background, the research published here sought to investigate ways in which moderately complex endodontic treatment might be made available within the NHS and through the medium of dentists with special interests (DwSI) in the discipline who had undergone additional training. The model might be represented as serving a half-way house between general dental practice and specialist referral, taking different but important pressures off each type of provision but to the advantage of all, including most importantly, the patient.

The results of this very laudable scheme indicate that the model studied may give clues to a way forward in this and other specific treatment areas. Perhaps ironically some of the pressure to make the service available came from the implementation of the NHS dental contract in 2006, which introduced the unit of dental activity (UDA) system of remuneration and created a rise in referrals to hospital-based services. Planning service provision may not be a challenge that we all take up but it remains central to the direction of our careers and livelihoods.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 217 issue 3.

Stephen Hancocks

Editor-in-Chief

Author questions and answers

1. Why did you undertake this research?

The training of dentists with extended skills (or DWSIs) in endodontics in London was a project introduced to address issues around skills and capacity to provide endodontic treatment of moderate difficulty within the NHS. The research team came to this project from restorative dentistry, dental public health and education with a shared goal of evaluating this pilot scheme through the use of mixed methods research to gain a comprehensive understanding of the project and provide learning for the future. We were interested in investigating the views of the different stakeholders, examining the service activity resulting from the programme against the criteria for endodontics of moderate complexity, and evaluating the effectiveness of the different triage models used. We were keen to ensure that the learning from our research is shared with the wider profession, Health Education England and policy makers, to inform the future direction of this and other similar schemes commissioned by the NHS.

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

Within England, the move to a single unified system for commissioning NHS dentistry provides the opportunity for the development of care pathways. It will be important to assess the effectiveness of care pathways in delivering patient care in the longer term; the cost effectiveness of established DwSIs in comparison with specialists; to compare the need for DwSIs in the different branches of dentistry; and different parts of England, where the availability and demands on specialist services might be different; and to explore the implications for professional careers. Future work in this area should also use prospective methodology and involve comparisons where possible.

Commentary

Introduction of the new contract in 2006 resulted in an increase in endodontic referrals to hospital-based services and has led to the development of strict local referral criteria. Some teaching hospitals can accommodate a limited number of patients, but treatment must be appropriate for undergraduate or postgraduate education. A small number are treated by postgraduate trainees. All dental graduates are qualified to carry out root canal treatment of teeth of straight-forward morphology. The endodontic related outcomes described in the General Dental Council's (GDC) First five years for a graduate is that he/she must be able to undertake appropriate nonsurgical treatments to manage pulpal and peri-radicular disease for uncomplicated deciduous and uncomplicated permanent teeth, recognise and be able to manage any associated risks, evaluate the need for more complex treatment and refer accordingly

Entry to specialist training for candidates with an MFDS or equivalent follows at least two years of general professional training and is competitive. Training programmes must be for a period of three years or 4,500 hours. As for the other restorative specialties, the programme for endodontics includes a broad based training in all aspects of restorative dentistry and clinical dental science. Sixty percent of the trainee's time is clinical, 25% academic and 15% research.

For some time a solution to the management of the patient requiring root canal treatment of moderate complexity has been proposed in the form a dentist with a special interest/dentist with extended skills (DwSI). The aim of this study was to seek stakeholders' views on an initiative to train dentists with a special interest in endodontics in conjunction with the NHS. Guidelines for the appointment of dentists with a special interest in endodontics were published in 2006 and describe a competency framework and evidence of maintenance of competencies. This paper describes the results of an audit of four models of care, structured interviews and questionnaires. Implications of funding arrangements were considered and the potential for this service to develop is discussed.

It was found that 1,600 teeth were treated by four dentists over a period of two years. Patients were said to be satisfied or very satisfied and the local dentists felt that having access to such services supported their patients.

There is no doubt that the DwSI model has a significant role within NHS endodontic services and this paper highlights the generally positive feedback from a variety of sources and of some need to refine the model for local use.