Planning and developing the dental workforce of the future.
A survey of the dental workforce in North East England and North Cumbria.
May 2016
Newcastle University
School of Medical Education
School of Dental Sciences
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The project was conducted between January 11th and May 31st 2016 by Gillian Vance PhD, MRCPCH, Richard Holmes PhD, FDS, RCPSG; Bryan Burford PhD and Ethan Shapiro MSc, Newcastle University.
This report was prepared by all members of the study team and the draft final report delivered to the Postgraduate Dental Dean, Mr Malcolm Smith, Health Education England North East & North Cumbria on May 31st 2016.
Acknowledgements
The authors would like to thank the various stakeholders and other individuals who supported, advised and facilitated the project. Firstly, Mr Malcolm Smith, Postgraduate Dental Dean, and Mrs June Wright, Dental Business Manager at Health Education North East provided helpful direction on project conduct and commentary on study progress.
There were a number of members of the Project Advisory Group whose input to survey design, support with data collection and review of report findings were invaluable. These colleagues were Paul Blaylock, Ollie Bailey, Margaret Corson, Rye Mattick, Tom Robson, Neelam Sharma and Duncan Thomas. We thank them enormously for their time and expertise.
We are also grateful to a number of individuals who supported data collection in their respective areas. These include Vicky Graham (prison dental services), Janice Paxton (HR, Newcastle upon Tyne Hospitals NHS Trust) and all the clinical leads for the salaried dental services in the region whose time to gather and discuss data was very much appreciated. These colleagues were Steve Jones, Emma Hoyles (Cumbria), Jane Lee (Northumbria), Marie Holland (South Tyneside), Solape Adeboye (Durham & Darlington), Judi Breckon (Teesside) and Graham Walton (Newcastle).
Also, we would like to thank HR staff in other secondary care Trusts, teaching staff in educational institutions, and not forgetting the large number of primary care dentists and practice managers who completed the questionnaire and helped create a comprehensive profile of the dental workforce in this region.
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ii Foreword
Dear Colleagues,
I am delighted to be able to introduce the 2016 Dental Workforce survey, carried out on behalf of the Dental Directorate and Health Education England by Newcastle University.
This is the most comprehensive Dental Workforce Survey to be completed since 2006 and I would like to take this opportunity to thank the Newcastle University team of Gillian Vance, Richard Holmes and Bryan Burford for their sterling efforts to ensure that the survey was completed by many elements of the Dental Workforce.
The delivery of oral health care and dental services is in the process of undergoing major changes and it is important that we understand the make-up of our current workforce and the pressures upon it.
This survey is not just about dentists but, quite rightly, about the whole dental team. It will form the basis of our workforce planning to develop a future strategy for the North East and North Cumbria, the outcome of which will be to ensure that patient services are focused on need and oral health improvement, delivered by a range of appropriately trained and competent dental professionals across primary and secondary care.
Malcolm Smith Postgraduate Dental Dean Health Education England working across North East and North Cumbria
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iv Executive Summary
Rationale
Newcastle University (School of Medical Education and School of Dental Sciences) was commissioned by Health Education England (North East and North Cumbria) to carry out a survey of the dental workforce in the region.
The last regional survey took place in 2006/7. Since then, there have been considerable developments in how dental services are commissioned and delivered. Changes in the dental workforce may be anticipated as a result of providers’ response to the ‘new’ General Dental Services contract and tariff system introduced in 2006, as well as the opportunities afforded by the General Dental Council’s review in 2013 of the scope and permitted duties of the wider dental team.
Hence, this survey sought to provide current data on the structure of the region’s dental workforce as the first step in a planned process of consultation with service providers. These findings will inform discussion between Health Education England (HEE) regional office and stakeholders on the needs for education and training of the local dental workforce, including development opportunities for the wider dental team.
Project design
A questionnaire-based survey was conducted across all sectors and practice locations where clinical dental personnel work. These included primary care practices delivering NHS and/or private services; salaried NHS community services; prisons and educational institutions. Data from secondary care settings were derived from the NHS Electronic Staff Record (ESR) system at each Trust.
Key findings
Data were collected from 228 primary care practices (a 53% response rate from all primary care practices identified in the region); NHS Trusts providing secondary care dental services; salaried dental services; all prison services and education institutions who train dentists and other dental care professionals.
Demographics
Men comprised 58% of all primary care dentists, while the vast majority of dental nurses and dental care professionals (DCPs) across all sectors were women. The majority of dentists in the salaried and prison dental services were women. Dental nurses and DCPs most commonly fell into younger age groups – 89% of all dental nurses in primary care and 68% of salaried service nurses were under 46 years age. Graduates of institutions in North East England made up the majority of the workforce (64% of dentists and 87% of dental nurses in primary care; 77% of salaried dental nurses).
v Working practices
Seventy-five percent of dentists indicated at least 99% of their work was in the provision of NHS services. As reported at practice level, the average NHS workload reported by respondents was 69%, which may reflect other professionals – such as hygienists, therapists and visiting specialists – who are also delivering private treatments. Notably a minority of dentists (14.7%) worked full-time in an individual practice, suggesting either that the proportion of dentists choosing to work part-time is rising compared with earlier figures, or that dentists are increasingly working across two or more practices. Similarly, part-time working is common in the salaried service, with just 25% of dentists working full-time. Sessional working in prison dentistry is the norm. There was limited seven-day working across the workforce.
Skill mix
Nurses comprised 38% of the total primary care workforce, with 11% made up by dental care professionals (most commonly dental hygienists and therapists). Dental nurses represent 46% of the salaried workforce. Whilst therapists and technicians formed a small part of the workforce, their numbers, in particular, have grown significantly in primary care, and there is now one therapist per eight dentists in the region. This compares to one therapist per 39 dentists in 2006/7. Eighteen percent of nurses were identified as ‘Extended Duty Dental Nurses’ (EDDNs) (10.5% in salaried services). The most common qualifications were in dental radiography, sedation nursing and oral health education. In around one third of primary care practices, nurses and other DCPs carried out additional activities, though across all sectors the extent of these activities fell short of the GDC’s full scope of practice for registrants (if suitably trained, competent and indemnified). On average, 65% of a dental therapist’s time was reportedly spent undertaking duties typical of a dental hygienist (43% for dental therapists in the salaried service).
Summary and further questions
The survey findings describe the current structure of the workforce in North East England and North Cumbria. It remains to establish how this structure relates to service delivery-in-practice and to patient care needs and expectations in the region.
Specific questions are:
1. How are dental care professionals (DCPs) with additional qualifications and/or extended skills used in service delivery? How can use of skill-mix be optimised? 2. What are the factors that influence retention of dentist and DCP staff in the workforce?
vi 3. How do current working practices – especially increased part-time and/or flexible working, impact on service models? 4. In what way may patients’ oral health needs and expectations in the region further inform workforce planning and shape a strategy for education and training?
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viii Contents Acknowledgements i Foreword iii Executive Summary v Rationale v Project design v Key findings v Summary and further questions vi Contents ix List of tables xi List of figures xi 1 Introduction 1 1.1 Rationale 1 1.2 Context – key developments in dental services over the last 10 years 1 1.3 Previous surveys 2 1.4 Objectives 3 2 Project design 4 2.1 Scope of survey 4 2.2 Data collection tool – questionnaire development 6 2.3 Project advisory group 7 3 Headline figures: The Dental Workforce in North East England & North Cumbria 8 3.1 Changes since 2006 9 4 Primary Care 12 4.1 Data collection method 12 4.2 Response rates 13 4.3 Details of Primary Care Practices 15 4.4 Composition of practice workforce 16 4.5 Staff profiles 19 4.6 Skill-mix and services provided 24 4.7 Vacancies, development and learning needs. 26 5 Secondary Care 27 5.1 Background 27 5.2 Method 27 5.3 Results 28 6 Salaried Dental Services 30 6.1 Background 30 6.2 Method 30 6.3 Results 31 7 Prisons 36 7.1 Data collection tool 36 7.2 Staff profiles 37 7.3 Dental care practitioner activities and specialised services 37 8 Educational institutions 39 8.1 Results 39 8.2 Dentists 40 8.3 Dental Nursing 40 8.4 Dental Therapist and Hygienists 41 9 Discussion 42 10 Areas of future work 43 References 45 Appendices 48
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x List of tables Table 1. Summary of data collection sources 7 Table 2. Headline figures of headcount and full-time equivalent staff in different groups across the sectors examined. 8 Table 3. Comparison of primary care workforce from 2006 and 2016 survey data. 10 Table 4. Full geographic response rates 13 Table 5. Summary of number of practices employing other staff groups. 16 Table 6. Summary of other staff in primary care (working within dental practice settings) 22 Table 7. Number of additional qualifications held by dental nurses in primary care. 24 Table 8. Number of practices at which specific duties are undertaken by DCPs 25 Table 9. Number of practices that reported delivering ‘more specialised’ services 25 Table 10. Summary of GDC-registered staff reported by secondary care Trusts. 28 Table 11. Summary of Salaried Dental Services 30 Table 12. Summary of dentist posts across salaried dental services 31 Table 13. Summary of other Dental Care Professionals in salaried dental services* 33 Table 14. Number of additional qualifications (NEBDN) held by dental nurses in salaried dental services. 33 Table 15. Specific ‘additional duties’ undertaken by DCPs in salaried dental services 34 Table 16. Details of locations of delivery of prison dental services across the region 36 Table 17. Summary of undergraduate/pre-registration dental training courses within North East England and North Cumbria. 39 Table 18. GDC-registered clinical academic staff employed directly by Newcastle University and linked to undergraduate teaching. 40 Table 19. Summary of places available on undergraduate dental training courses and indicative staffing (excluding BDS at Newcastle University) 41
List of figures Figure 1. Location of primary care practices and secondary care hospitals. 4 Figure 2. Composition of workforce (headcount) for each sector. 9 Figure 3. Returned and unreturned questionnaires from primary care practices, with response rates by geographic postcode area. 14 Figure 4. Distribution of reported NHS workload by practice. 15 Figure 5. Relative size of practices by number of dentists, dental nurses and other clinical roles 17 Figure 6. Number of practices working each day 18 Figure 7. Number of full-time and part-time dentists (headcount and fte posts), by age group and sex 19 Figure 8. Distribution of working hours reported for individual dentists. 20 Figure 9. Distribution of reported percentage of NHS working by individual dentists. 21 Figure 10. Summary of demographics of GDC-registered dental nurses and dental nurses in training. 22 Figure 11. Distribution of hours for salaried dentists. 32 Figure 12. Frequency of full and part-time salaried dentists by age and sex. 32
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1 Introduction
1.1 Rationale
Workforce planning is key to the development of effective and efficient health services. Its goal is to ensure that ‘the right number of people with the right skills are in the right place at the right time to provide the right services to the right people’ 1. However, in order to achieve this goal the process must be responsive to changes in patient needs and/or models of care delivery.
This regional survey set out to establish the profile of the multi-professional dental workforce in North East England and North Cumbria, across all sectors where dental personnel work. These include primary care practices delivering NHS and/or private services, secondary care and salaried community services delivered by the NHS, prisons and educational institutions.
The last such survey in the region was carried out in 2006/7 by the Northern Joint Dental Workforce Group 2. Since then there have been significant developments in the delivery of dental services, which are in turn likely to have affected the shape of the dental workforce.
1.2 Context – key developments in dental services over the last 10 years
Dental health care provision takes place in a complex and evolving environment, in which there have been significant developments in the population’s oral health needs 1,3 and treatment expectations 4, as well as changes in working practices 5, technological resources and the structure of service delivery. Consequently, the provision of dental care in the UK is associated with significant financial costs. To place the size of the UK dental market into context, relatively recent estimates from LaingBuisson put the value of UK primary care dentistry in 2013/14 at £5.8bn. This figure can be further divided into government and patient spending on NHS dentistry (£3.6bn or 63% of the market share) and spending generated by private dentistry (£2.2bn or 37% of the market share) 6.
In terms of the structure of service delivery, there have been a number of developments in the landscape of dental healthcare since the 2006/2007 North East report.
Firstly, in April 2006 the ‘new’ General Dental Services (nGDS) contract was introduced, along with ‘Units of Dental Activity’ (UDA) as a form of contract currency and a small number of patient charge bands. Since this time the contract and tariff system have received much criticism and caused resentment and job dissatisfaction among practitioners offering NHS services 4, 7, 8, 9. A resulting parliamentary inquiry and an independent review of NHS dental services 3 led to piloting (now prototyping) of a reformed NHS dental contract with a new remuneration system based on weighted capitation, registration and quality outcomes.
Secondly, the approach to commissioning of dental services within the NHS has changed. In 2006 (after implementation of the nGDS contract), the former Primary Care Trusts (PCTs) commissioned NHS primary care
1 North East and North Cumbria Dental Workforce Survey, 2016 dental services. However, with the reorganisation of the NHS in England that followed the Health and Social Care Act 2012 10, commissioning of dental services was devolved to NHS England (NHSE). This single national organisation, with a regional structure, has led commissioning since April 2013. The remit of NHSE also includes responsibility for directly commissioning dental services for persons detained in prison and other secure settings 11.
Thirdly, there has been significant legislative change affecting the scope and permitted duties of members of the dental team in the United Kingdom. In 2008, the General Dental Council (GDC) introduced statutory registration of dental nurses, dental technicians, orthodontic therapists and clinical dental technicians, and since then there has been a steady increase in the numbers of these registered Dental Care Professional (DCP) groups 12. In 2013, the GDC also removed its barrier to direct access for some members of the dental team, including dental hygienists and therapists, in specified circumstances. This change means that the multi-professional team can provide aspects of patient care in new ways, potentially allowing dentists to focus on more complex cases, with potential benefits for cost and ease of patient access 4.
Fourthly, during this period there has been an increase in dentists graduating from universities in England, as well as additional recruitment of overseas-qualified dentists 13. This followed an expansion in the number of dental training places in England, agreed after a workforce review in 2004 14. However, literature has shown that a wide range of factors may influence graduates’ career choices and decision to work in the NHS, including work-life balance and financial stability 3, 15. A recent national survey of community (salaried) dentists similarly highlighted staff concerns around pay and reward, whilst acknowledging their commitment to this vulnerable patient population 16.
Finally, there has been a change in the composition of primary dental care delivery in the UK, with the expansion of corporate bodies operating across a large number of practices. LaingBuisson’s 2014 ‘Dentistry UK Summary Market Report’ found that the corporate dentistry sector (defined as groups of three or more practices), was estimated to be worth £1.3bn and involving around 6,950 dentists in the UK in 2013/14. A further highlight was that the corporate dentistry market in the UK (in terms of market penetration) had increased from just over 12% in 2010 to 22% in 2013/14 6.
These recent and ongoing developments mean that it is timely to establish a picture of who comprises the modern dental team, and their associated responsibilities. This will provide an initial evidence base to guide planned consultation on the workforce planning strategy appropriate to the needs of North East England and North Cumbria.
1.3 Previous surveys
As described above, the most recent survey of the dental workforce in North East England and Cumbria was conducted in October 2006 2, following an intended baseline survey in 2004. There have been no regional surveys in the last decade. Additionally, those surveys considered only primary care, whereas ours considers all sectors in which dentists practice in the region – salaried, secondary and prisons – as well as academic staff.
2 North East and North Cumbria Dental Workforce Survey, 2016
Regular national surveys are conducted by the British Dental Association (BDA) and General Dental Council (GDC). However, these gain response rates far below the regional surveys – for example, the GDC survey of registrants in 2013 reported just a 16% response rate 17 – and their relevance is therefore hard to interpret, particularly with regard to the particular workforce needs of North East England and North Cumbria.
Reports on the Scottish 18 and Welsh 19 dental workforces used secondary data sources to provide an overview of the workforce and forecast ‘supply and demand’, with the former focusing on dentists and the latter on all staff. However, such an approach does not provide the same contextual information about how staff are deployed in practice, for which a survey of practice locations is necessary.
1.4 Objectives
The primary purpose of this survey was to provide current data on the structure of the region’s dental workforce to inform a regional consultation on future workforce planning.
A secondary objective was to identify training opportunities or gaps. Knowledge of these will further inform discussion between the Health Education England (HEE) local office* and stakeholders about the education and training needs of the local dental workforce, including development opportunities for the wider dental team.
* Previously known as Health Education North East (HENE).
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2 Project design
2.1 Scope of survey
The survey was geographically limited to the dental workforce in the North East of England and North Cumbria, across which the Health Education England local office has responsibility for the commissioning of postgraduate dental education and training in order to fulfil the workforce requirements of the local healthcare economy. Figure 1 illustrates the geographical distribution of primary care practices and secondary care, hospital sites where dental care is provided.
Figure 1. Location of primary care practices and secondary care hospitals.
Map data copyright Google Maps. Location data derived from postcodes and plotted using the RGoogleMaps package in R. Note that urban areas have a density of practices that this level of resolution does not show.
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In order to build an inclusive profile of the region’s dental workforce, survey data were gathered across primary care (both NHS and private sectors), secondary care, salaried dental services, prison dental services and educational institutions (see Box Box 1. Scope of services covered in survey. 1). Primary care. Locations that provide primary dental care The survey considered all dental professionals services to the public. All primary care practices are private businesses, which may be owned by individuals, registered with the General Dental Council partnerships or by corporate organisations. Some (GDC): namely dentists; dental nurses; practices treat only private patients, while others are contracted by the NHS, where remuneration is based on orthodontic therapists; dental technicians; UDAs. Many will treat both private and NHS patients. Primary care practices in the region were identified from clinical dental technicians; dental hygienists and the publicly available Care Quality Commission database, dental therapists. in which all locations delivering healthcare must be registered.
Data were also sought about groups operating Secondary care. NHS Trusts that provide orthodontic, oral in essential support and managerial roles, such surgery or dental services in a hospital setting. Four Trusts in the region provide such services: Newcastle Upon Tyne as practice managers, receptionists and Hospitals NHS Foundation Trust, City Hospitals Sunderland administrators, recognising that some of these NHS Foundation Trust, South Tees NHS Foundation Trust and North Cumbria University Hospitals Trust. responsibilities will be performed by GDC- Postgraduate trainees working in secondary care across the region are employed by the Lead Employer Trust registered professionals working in dual roles (County Durham and Darlington NHS Foundation Trust). within practices. Salaried dental services. NHS services that deliver a range of clinical and public health activities, most commonly in the community setting. Dental care is often provided to more vulnerable patient groups and treatments may have a greater specialised component than delivered in primary care.
Prison dental services. Dental services are delivered to seven prisons – 5 adult male, one female, one young offender institution – across the region. Since 2013, the contract has been commissioned directly by NHS England. It is held by a single provider in this region.
Educational institutions. Education and training in dental care professions is delivered in a number of educational institutions across the region, including the School of Dental Sciences at Newcastle University.
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2.2 Data collection tool – questionnaire development
Although the sectors of dental care delivery under study vary considerably, the constituent staff groups are the same, and so a common tool was developed in order to capture data in as comparable a form as possible. As the majority of the dental workforce work in primary care, the questionnaire was based on this sector. Questionnaire design took account of the depth and detail of data required, along with a need to keep the questionnaire as brief and clear as possible, in order not to deter respondents.
An initial draft questionnaire was developed from the brief supplied by HEE, with formatting and presentation revised following feedback from the project advisory group (PAG) and pilot completion in a medium-sized primary care practice. The final version contained items recording:
Practice ‘type’ (eg. independent, group or corporate) and the proportion of all work carried out in the practice under an NHS contract. The number and demographics of practitioners in all staff groups. The full-time-equivalent (fte) hours worked by all staff. Vacancies in any staff group. Place and type of staff qualifications. Specialised or specialist-delivered services available in the practice. Activities performed by dental care professionals. Free text, including comment on suggested staff development or learning needs.
The questionnaire was then adapted for the salaried and prison dental services. A copy of the full primary care questionnaire is included in Appendix A. In order to support web-based survey completion, online versions of the final questionnaire were also set up on the Qualtrics platform (www.qualtrics.com).
Due to the desire to maximise data collection, the questionnaire was constructed such that partial data entry was possible. For example, the number of dentists was captured separately to the individual dentist information in case the details of individual dentists were not given. For non-dentist staff groups the numbers of male and female staff members were obtained separately from the numbers in each age group. This means that there may be some variation in the numbers presented through this report, if data are derived from different questionnaire items.
Data were summarised and analysed using the R statistical programming language (www.r-project.org). In calculating the extent of full-time working, we assumed 37.5 hours per week to be the common criterion, as this is the standard figure in NHS organisations. We realise that this will not be the case for some staff whose full-time hours are greater, but in the absence of this level of detailed information, the use of a common denominator allowed a straightforward comparison. Also, we did not distinguish between ‘clinical’ and ‘administrative’ hours for dentists and DCPs, but guidance from the Project Advisory Group (see section 2.3) suggested that the working hours reported were most likely to relate to clinical (patient contact) time.
Table 1 summarises data collection for each sector. Full details of each are given in subsequent sections.
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Table 1. Summary of data collection sources
Sector Data Source; data purpose Details of locations included Primary Care Care Quality Commission register of practices 431 practices in NE and N Cumbria. Data for workforce delivering general dental services in primary care. Secondary Care NHS Electronic Staff Record (ESR) system at 4 Trusts as: each Trust. Newcastle Upon Tyne Hospitals NHS Foundation Trust Data for the dental workforce directly City Hospitals Sunderland NHS Foundation Trust employed by NHS organisations. South Tees NHS Foundation Trust North Cumbria University Hospitals NHS Trust Graduate trainees Lead Employer Trust ESR record. Data on dentists in Dental Foundation training (Dental Foundation Register) and Specialty Training posts. Salaried Services Clinical Director and/or HR representative. Newcastle Upon Tyne Hospitals NHS Foundation Trust Data for the salaried dental service Cumbria Partnership NHS Foundation Trust workforce delivered by NHS organisations. N Tees and Hartlepool NHS Foundation Trust S Tyneside NHS Foundation Trust Northumbria Healthcare NHS Foundation Trust County Durham & Darlington NHS Foundation Trust Prison Dental Service Service provider 7 prisons (6 North East; 1 North Cumbria) Higher/Further Education Course lead; course website. Newcastle University Institutes Data on the dental academic / teaching Teesside University workforce employed by Newcastle University New College Durham Dental School or other educational Newcastle College organisations. Sunderland College Data on undergraduate dentists, as well as Carlisle College. other dental care professionals in training.
2.3 Project advisory group
An expert project advisory group (PAG) provided guidance and feedback to the research team at different stages of the project. The PAG included representatives from primary care dental practices (including private practice), secondary care and prison dental services. The group also included leads for Dental Foundation training and representatives of clinical networks (both Local Professional Networks and Local Dental Committees).
The group met three times, and members were also able to provide comment via email. The first meeting reviewed results of the initial questionnaire pilot, refined the draft questionnaire and discussed a strategy for questionnaire distribution in primary care. At this meeting, the members advised the team to include an ‘incentive’ (a ‘prize draw’) to enhance the likely response rate by encouraging practices to return the questionnaire. The second meeting reviewed the progress of primary care data collection and the procedures proposed for other settings. At the third meeting, the group reviewed the draft report and gave feedback on findings.
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3 Headline figures: The Dental Workforce in North East England & North Cumbria
This section summarises the headline workforce figures across all sectors (table 2). These include the total number of individuals employed (headcount), and the total number of full-time posts derived from the total hours worked (full-time equivalent, fte). Note that primary care figures are those of respondents to the questionnaire, representing around 53% of practices. We cannot know how practice size compares between respondents and non- respondents, but a rough indicator of actual workforce numbers may be to double the figures (although see comparison with figures of GDC registrants in Appendix C).
Table 2. Headline figures of headcount and full-time equivalent staff in different groups across the sectors examined.
Staff group Primary care Secondary Care Salaried Prison Total (respondents) h/c* fte** h/c fte h/c fte h/c fte h/c fte Dentist 804 561 219 117 107 70 7 1.3 1,118 737 Dental nurses 1090 557 141 109 128 95.5 6 4.3 1,345 753 Dental nurses in training 179 113 0 - 1 1 1 0 180 114 Dental therapists 99 39 0 - 8 3.5 1 0 108 41 Dental hygienists 158 40 13 † 6 6 3 0 0 177 47 Dental technicians 18 16 31 25 2 2 0 0 51 43 Clinical dental technicians 10 3 0 - 0 0 0 0 10 3 Orthodontic therapists 22 10 0 - 0 0 0 0 22 10 * h/c = headcount – the number of individuals reported ** fte = the full-time equivalent number of posts, rounded to the nearest integer. These figures are calculated by dividing the total number of hours worked by each group by 37.5. While actual full-time hours may vary between organisations, using a standard working week allows comparisons to be made † Includes joint therapist/hygienist roles
In these figures the number of fte posts is the more important, as the headcount figure may include multiple instances of individuals who work in more than one location. The relationship between headcount and fte is a complex one that will need close attention in the development of workforce strategy.
It is notable in the primary care figures that while nurses are the biggest group in terms of headcount, the fte figures are similar to those of dentists, suggesting more nurses work part-time. The hours worked by dentists may be amplified by the inclusion of business management and administration time (though the PAG advised that the reports given were most likely related to patient contact time).
Figure 2 illustrates the composition of the workforce in each of the sectors.
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Figure 2. Composition of workforce (headcount) for each sector.
Figures in charts represent the percentage of total workforce in that sector. * Dental technicians (working in dental practices) and orthodontic therapists each constitute 1% of primary care workforce.
3.1 Changes since 2006
The focus of our report differed in some respects from that carried out in 2006, but captured much of the same data regarding workforce numbers and demographics. Comparisons of these data are summarised in table 3. While consideration of these must bear in mind that both samples were in the region of 50% of the population, we assume that the figures are comparable.
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Table 3. Comparison of primary care workforce from 2006 and 2016 survey data.
2006 data * 2016 data Comment
Response rates (see section 4.2, p13) 49% overall (210 of 426 practices) 53% overall (228 of 431 practices) The total number of practices has remained static, with an increase of just 0.1% County Durham and Darlington 40% Durham and Darlington (DH and DL Within the region, response rates in 2006 were Cumbria 37% postcodes) 59% given by clusters of Primary Care Organisation North of Tyne 59% Carlisle (CA) 43% (PCO). In 2016, this can be approximated only by postcode areas. South of Tyne 62% Newcastle, North Tyneside, Response rates by sub-region are favourable Teesside 39% Northumberland, Gateshead (NE and TD) 53% compared to 2006, with the exception of Sunderland (SR) 46% Tyneside. However, this is confounded as postcode areas are not coterminous with PCO Teesside (TS) 56% areas. for example the NE postcode area includes north and south of Tyne.
Size and composition of workforce (see section 4.3, p15) Dentists: 587 – 2.8 per practice Dentists: 804 ( 37% since 2006) – 3.5 Increases in headcount should be considered Dental nurses: 591 – 2.8 per practice per practice in the context of 8% more practices reporting. Therapists: 12 – 0.06 per practice Dental nurses: 1090 (84%) – 4.8 per There are substantial increases in numbers of some staff groups. Hygienists: 149 – 0.71 per practice practice Technicians: 4 – 0.02 per practice Therapists: 99 (725%) – 0.4 per practice Practice Managers: 64 – 0.3 per practice Hygienists: 158 (6%) – 0.7 per practice Receptionists: 205 – 0.98 per practice Technicians: 18 (350%) – 0.08 per Joint roles – 365 practice Practice Managers: 172 (169%) – 0.75 per practice Receptionists: 343 (67%) – 1.5 per practice Nurse:dentist ratio of 1.5 Nurse:dentist ratio of 1.4 1 therapist per 39 dentists 1 therapist per 8 dentists
Dentist demographics (see section 4.5, p19) Male: 347 (64%) Male: 455 (58%) The dentist workforce is still predominantly Female: 199 (36%) Female: 331 (42%) male, but there has been a movement towards equal representation. Male Female Male Female The distribution of dentists by age group Under 30 18% 30% Under 30 19% 25% appears to have remained fairly static for both 30-44 46% 53% 30-45 43% 53% male and female dentists. The continued drop- off in numbers after 45 years (sharper for 45-54 24% 16% 46-55 24% 17% women) raises questions about the retention Over 50 11% 2% Over 55 15% 6% of these dentists in the sector.
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2006 data * 2016 data Comment
Other staff (see section 4.5, p19) Male: 582 (35%) Male: 78 (4%) The 2006 data collapsed all non-dentist staff – Female: 1060 (65%) Female: 2006 (96%) dental therapists, hygienists, nurses, technicians, practice managers, receptionists, and 'others'. Male Female Male Female The big decrease in male numbers is hard to (n=582) (n=1060) (n=71) (n=1825) interpret. While it is not impossible that the Under 30 26% 5% Under 30 4% 44% gender distribution has changed radically, a more fundamental difference in data seems 30-44 23% 14% 30-45 24% 38% more likely. The lack of granularity in the 2006 45-54 4% 31% 46-55 25% 13% data with regard to staff groups makes this Over 54 46% 50% Over 55 21% 5% hard to elaborate. However, superficially it least it seems as though a younger female workforce predominates.
Full and part-time working (see section 4.5, p19) Dentists Male Female Male Female There has been a large increase in part-time Full-time 226 (66%) 95 (42%) Full-time 78 (18%) 40 (12%) working (in a single practice), which is more Part-time 116 (34%) 131 (58%) Part-time 357 (82%) 284 (88%) pronounced for males. Other staff Other staff Male Female Male Female Individual hours were not obtained for non- Full-time 39% 43% Full-time 56% 58% dentists in our questionnaire, so estimates of Part-time 61% 57% Part-time 44% 42% full-time numbers are derived from fte hours for staff groups, where given. While there may be a slight move towards full-time working on the basis of these figures, it is possible that there are fewer full-time posts than indicated.
Nursing workforce (see section 4.5, p19) 593 (66%) dental nurses reported as 1006 (92%) of all nurses indicate a The requirement for nurses to be registered being qualified. recognised qualification. with the GDC was new in 2006. Today all dental nurses must be registered and all new nurses are therefore qualified. Some nurses practising before the introduction of registration could register by grand-parenting procedures without obtaining a recognised qualification. 90 practices (43%) had supervised nurses 123 practices (54%) reported at least one These figures may suggest a higher number of in training. trainee dental nurse. practices providing dental nurse training
NHS activity (see section 4.3, p15) Practices reported a mean of 82% NHS Practices reported a mean 68% NHS work work. although this masks a bimodal distribution, and a median of 90%.
Vacancies (see section 4.7, p26) Reported as number of hours required; Free text – 17 practices actively mostly small numbers – largest shortfall recruiting, or would like to recruit a 11 fte nurses (436 hours) dental nurse, 4 wished to advertise for a dental therapist, two a hygienist & six a dentist. * Data from the 2006 survey carried out by the Northern Deanery Joint Dental Workforce Team 2
11 North East and North Cumbria Dental Workforce Survey, 2016
4 Primary Care
4.1 Data collection method
All premises providing dental services must be registered with the Care Quality Commission (CQC). The CQC register, published weekly on the CQC website, was therefore used as the source of the distribution list for the primary care questionnaire. The register dated 13 January 2016 was used to develop the distribution list, with any changes monitored weekly until distribution was complete – no changes to practices or addresses were made in that time.
Development of the distribution list involved limiting the register to premises categorised as providing dental care under the field ‘Service type’, located in the North East under the field ‘Region’ or with a postcode beginning ‘CA’ (Carlisle postcodes, which cover North Cumbria). Once duplicate entries were removed, this left 434 primary care practices.
Distribution of the questionnaire took account of the literature around ways of enhancing survey response rate. Measures included pre-survey notification by email, personal contact from academic staff, several follow up contacts, an extended period of survey availability and use of an ‘incentive’ 20.
All practices for which email addresses could be identified were sent two email notifications about the project – the first on 1 February and then again on 3 March 2016.
Practices were sent a hard copy of the questionnaire by post on 7 March 2016. Included with the questionnaire was a summary of the rationale for each question. This document was drafted by the Postgraduate Dental Dean (Mr Malcolm Smith), in order to explain the purpose of the requested information and thereby enhance the salience of the survey to the respondents.
Each questionnaire contained the link to the online version, with a unique identifying number (although if this was lost, postcode and practice name could still be used for identification purposes). A slip advertising the draw for £500 was also included, and a sticker placed on each envelope advertising ‘Dental Workforce Survey 2016’, with the Newcastle University logo.
Regular reminders about the questionnaire were cascaded indirectly through local networks, and a global email reminder sent from the research team on 7 April. A second paper copy was sent to non-respondents on 12 April 2016. A summary of the data collection strategy is shown in Appendix B.
12 North East and North Cumbria Dental Workforce Survey, 2016
4.2 Response rates
By 20 May 2016, 228 questionnaires had been returned (172 [75.4%] returned on paper, 56 [24.6%] completed online). Of the original 434 practices, one notified us that they had closed during the period of the survey, and two had been removed from the CQC database by the end of data collection and so were assumed to have closed (both hard copies sent to one of these had been returned undelivered).
Of the remaining 431 practices, our return of 228 questionnaires constituted an overall response rate of 52.9%. This response rate is comparable to that achieved in 2006/7, when there was a 49% response rate. Indeed, it is much greater that the response anticipated by the literature on questionnaire-based research methods, which have cited a response rate of less than 40% for paper-based surveys that are administered in a non-face-to-face context 21. It also far exceeds other workforce studies of dental staff, such as the 16% achieved by the GDC in 2013 17 and 26.5% by the BDA in 2012 22.
Figure 3 summarises the response rate from all practices in postcode areas across the region. This shows some variation in responses, but that all areas returned at least 40%. Full figures are given in table 4.
Table 4. Full geographic response rates
Postcode area Number of Number of Response practices* responses rate Carlisle – North Cumbria (CA) 53 23 43% North County Durham (DH) 45 22 49% South County Durham (DL) 40 28 70% Newcastle, North Tyneside, 173 90 52% Gateshead, Northumberland (NE) Sunderland (SR) 33 15 46% North Northumberland (TD) 5 4 80% Teesside (TS) 82 46 56% Total 431 228 53% * Excluding those returned undelivered. This number includes practices offering NHS and/or private dental treatments.
13 North East and North Cumbria Dental Workforce Survey, 2016
Figure 3. Returned and unreturned questionnaires from primary care practices, with response rates by geographic postcode area.
In order to interpret the response rate in terms of representation of those registered with the GDC, data were compared with national and regional data held by the GDC obtained by a Freedom of Information Act request. This is summarised in Appendix A, and indicated that the numbers of individuals represented in these responses were overall proportional to registrants in the region and England as a whole. This suggests minimal response bias in terms of the size and type of practices reported.
Additionally, we considered responses by practice type – namely, those that are members of dental corporate bodies (large companies that own and operate a number of practices, often nationally), small groups (local companies operating a small number of practices) and individual practices. The response rates were similar for these different sectors: corporates 46% (33/72), small groups 56% (35/63) and individual practices 54% (160/296). This suggested that while there was a slightly lower response rate from corporate-owned practices, those organisations were not significantly under-represented.
14 North East and North Cumbria Dental Workforce Survey, 2016
4.3 Details of Primary Care Practices
Practice provision of NHS versus Private dental services
Figure 4 illustrates the proportion of NHS workload reported by practices, with quartiles indicated by vertical lines. The distribution is clearly bimodal, with a cluster of practices at the lower end representing twenty eight practices (13%) providing solely private care, and the larger peak at the upper end showing a larger proportion for whom the majority of practice is under an NHS contract. The average percentage of NHS provision per practice was 68%, which masks this bimodal distribution. This contrasts with the 2006/7 survey where the average percentage of NHS workload per practice was 82% and ranged from 60% (former Cumbria PCT) to 90% (former Teesside PCT).
It is likely that these figures will include services provided by staff other than the dentists employed in the practice – such as therapists or hygienists within the practice working with private patients, or visiting specialists.
Figure 4. Distribution of reported NHS workload by practice.
Histogram presenting distribution of proportion of NHS workload by practice. The centile markers indicate that 25% of practices delivered less than 46% NHS care, but that 50% delivered at least 90%, and 25% delivered at least 96%
There was no correlation between the size of practice, as indicated by total staff numbers, and the proportion of NHS care reportedly delivered, nor any significant difference between the percentage delivered by corporate, partnership or single-ownership practices.
Size of practices
Most practices (n=102) reported being owned by an individual, while 72 were owned by partnerships, and 40 were members of corporate groups.
The majority of practices were small, with a median of three dentists. This was true of both NHS and private practices, although the largest private-only practice employed seven dentists, while some NHS practices employed
15 North East and North Cumbria Dental Workforce Survey, 2016 as many as 15. The mean number of dentists was larger among predominantly NHS practices (3.8 compared to 2.6 for predominantly private). Corporate practices also tended to be larger, with a mean of 4.4 dentists compared to 4.2 for partnerships and 2.8 for single owners.
The range and median of other staff groups are given in table 5. All but three practices reported employing dental nurses, while very few practices employed orthodontic therapists (6/228), dental technicians (6/228) or clinical dental technicians (5/228). Many dental technicians will work in independent businesses outside of the dental practice environment – as they are not treating patients these premises do not require CQC registration and so would not have received our questionnaire (http://www.cqc.org.uk/content/registration-dentists-care-settings).
Table 5. Summary of number of practices employing other staff groups.
Number (and %) of Range of Median staff employing staff number practices * numbers Dental therapist 73 (32%) 0-9 0 Dental hygienist 104 (46%) 0-6 0 Dental nurse 220 (96%) 0-65** 4 Dental nurse in training 120 (53%) 0-5 1 Clinical dental technician 7 (3%) 0-3 0 Dental technician 6 (3%) 0-12 0 Orthodontic therapist 10 (4%) 0-6 0 Practice Manager 159 (70%) 0-5 1 Receptionist 167 (73%) 0-10 1 * Number is frequency within sample only. ** The figure of 65 refers to a response from a practice working across multiple sites.
The majority of practices (165; 72%) reported employing a practice manager. Of these, 133 (81%) indicated that the practice manager (or at least one, if several were employed) was a GDC-registered dental professional.
4.4 Composition of practice workforce
Figure 5 summarises the size of practices by the mean numbers of dentists, nurses and other staff. Data are presented for practices which reported that they were ‘exclusively or mostly NHS’, and those ‘exclusively or mostly private’, and for different forms of ownership – corporate, partnership or single owner.
The ratio of dentists to other dental care professionals was slightly higher in those practices categorised as ‘exclusively or mostly NHS’ compared to those ‘exclusively or mostly private’. Single owners of dental practices reported a difference in terms of their staffing depending upon whether they were ‘predominantly NHS’ or ‘predominantly private’. Single owners of predominantly NHS practices reported a relatively high proportion of dentists and low proportion of ‘other clinical staff’, whereas in the predominantly private practices the opposite
16 North East and North Cumbria Dental Workforce Survey, 2016 was true. Indeed, in single owned private dental practices ‘other clinical staff’ approached one third of the workforce, compared to around 20% in singly owned NHS practices.
Figure 5. Relative size of practices by number of dentists, dental nurses and other clinical roles
Plot distinguishes between mainly NHS practices (n=153) and mainly private practices (n=54), and those owned by corporate bodies, partnerships or single owners. Numbers on plot are the number of individuals reported in each professional staff group.
Pattern of practice opening
Figure 6 illustrates the number of practices that have dentists working each day. The distribution of dental care through the week, as indicated by the days of the week worked by each dentist in each practice, was consistent through the working week of Monday to Friday. Around 95% of practices were open each day of the working week, and around 18% were open on Saturdays. Just one practice reported working on Sunday. However, the number of hours open at weekends were not supplied, and as we did not distinguish between dentists’ administrative and clinical hours of work, it may not mean that practices are open to patients at these times.
17 North East and North Cumbria Dental Workforce Survey, 2016
Figure 6. Number of practices working each day
Numbers on bars indicate the number of practices reporting that dentists work on those days.
18 North East and North Cumbria Dental Workforce Survey, 2016
4.5 Staff profiles
This section provides a more detailed breakdown of the staff reported in each occupational group. This again gives headcount and full-time equivalent (fte; assumed in this study to be 37.5 hours per week, see section 2.2), with demographic data (sex and age), where available. It also gives the ratio of headcount to fte, which indicates the extent of less-than-full-time working in each group. A ratio of 1 means that all posts are filled full-time. A ratio of greater than one means that there are more people than fte posts and is an indication of the extent of part-time working in individual practices.
Dentists
There were more male than female dentists (58% of those who indicated their sex ; n=455 male, n=331 female, plus 14 not given). The demographic breakdown of data for headcount, fte posts, and the number of dentists working full-time indicated a greater presence of male dentists in older age groups (79% of over-55s and 66% of 46-55 year olds), but no difference in younger age groups (52% and 53% male in the younger two age-groups). Figure 7 indicates the number (headcount) of full and part-time dentists by age group and sex. Respective percentages for males and females were: males under 30 years, 19%; 30-45 years, 43%; 46-55 years, 24%, over 55 years, 15%. Females: 25%, 53%, 17%, 6%.
Figure 7. Number of full-time and part-time dentists (headcount and fte posts), by age group and sex
Of the 804 dentists working in the primary care practices responding to the survey, just 118 (14.7%) reported working at least 37.5 hours per week in that practice, although, as figure 8 shows, the median figure of 30 hours per week indicates that many were working close to this amount. Additionally, the figure of 37.5 hours may not be appropriate for dentists recording only clinical contact time, and so the number working 'full-time' may be higher.
The full-time equivalent number of posts was 561, giving an overall headcount:fte ratio of 1.4 – meaning 1.4 individuals were working for each full-time equivalent post.
19 North East and North Cumbria Dental Workforce Survey, 2016
It is also important when considering these figures to emphasise that they represent dentists at each site, and do not track individuals who may work across different sites – two dentists, reported to be working at 0.5 fte at two sites, could in fact be one individual working full-time hours.
Figure 8. Distribution of working hours reported for individual dentists.
Histogram presenting distribution of reported working hours. The centile markers indicate that 25% of dentists worked less than 20 hours per week in a given practice, but that 50% worked at least 30 hours, and 25% worked at least 35 hours.
The overall proportions of female and male dentists working part-time were significantly different (88% of women and 82% of men). This also suggests a notable drop from 2006/7, when figures were 83% of women and 61% of men.
The proportion of NHS work carried out by each dentist in a practice was also recorded. Figure 9 presents the distribution of this figure across all dentists. While there were missing data on this variable, a dentist working in a wholly private practice was considered to be delivering no NHS work. The 63 dentists identified as Foundation Dentists at 42 practices were omitted from this analysis. While they are not restricted from treating patients privately, their practice in this sector is generally very small. The distribution therefore represents data from 562 (76%) individual dentists. The overall pattern is similar to that for practices. It is comparable to data from the Centre for Workforce Intelligence, which reported that 72% of dentists did more than 75% NHS work (the 25th centile here being 80%) 13.
20 North East and North Cumbria Dental Workforce Survey, 2016
Figure 9. Distribution of reported percentage of NHS working by individual dentists.
Histogram presenting distribution of proportion of NHS workload by individual dentist. The centile markers indicate that 75% of dentists delivered 80% NHS care, and 50% delivered at least 95% NHS care.
The majority of dentists were described as having been trained locally in North East England (513, 64%), with 172 (21%) qualifying elsewhere in the UK, 36 (5%) elsewhere in Europe and 14 (2%) indicating 'not known'.
Dental Care Professionals (DCPs)
For dental care professionals (other than dentists), data on individuals were not recorded in order to keep the questionnaire concise and so encourage maximum response. Demographic and fte data were therefore aggregated at the level of practices.
Dental Nurses
Dental nurses constitute 38% of the total primary care workforce (n=1090). Figure 10 summarises the demographics of qualified and trainee dental nurses. The vast majority were female (n=1067, 98% of those where this information was given), and this finding looks to continue with those currently in training (98% of the 179 trainees are female). The majority were also young, with 90% being under 46 years. The lack of dental nurses older than this raises questions about their longer-term retention within the workforce, and their destinations if they leave, or change roles within dentistry.
21 North East and North Cumbria Dental Workforce Survey, 2016
Figure 10. Summary of demographics of GDC-registered dental nurses and dental nurses in training.
Most nurses (944, 87%) qualified in North East England, with 66 (6%) qualifying elsewhere in the UK, and just 2 (<1%) elsewhere in the EEA.
Most nurses had Level 3 diplomas (984; 527 from the NEDNB, 457 City and Guilds NVQ), and 22 a certificate of higher education. Overall, qualification details were not given for 79 nurses, which might suggest that these practitioners may have been allowed to join the GDC register on the basis of experience (a process known as ‘grand- parenting’).
Other registered Dental Care Professionals
Other GDC-registered professional groups constituted 11% of the workforce (n=307). The majority (84%) of these were recorded by respondents as either dental hygienists (n=158) or therapists (n=99). The demographics of these groups, and of orthodontic therapists, were similar to nurses, with the majority being female, under 45, and qualified in the North East. By contrast, dental technicians and clinical dental technicians were mainly male, although numbers were much fewer (due to the fact that only dental practice settings were considered in our questionnaire survey). None qualified outside the UK. Table 6 summarises the key figures for these groups.
Table 6. Summary of other staff in primary care (working within dental practice settings)
Job Headcount fte Headcount:fte % female % under 46 % qualified in North ratio East England Dental therapist 98 39.4 1:2.5 97% 96% 78% Dental hygienist 149 38.5 1:3.9 98% 64% 93% Orthodontic therapist 19 8.8 1:2.2 100% 100% 68% Dental technician 25 22.8 1:1.1 2% 52% 68% Clinical dental technician 7 2.1 1:3.3 0% 71 57%
22 North East and North Cumbria Dental Workforce Survey, 2016
Practice managers and receptionists.
There were 171 practice managers in total filling 122 fte posts with a headcount:fte ratio of 1.4. Of these, 96% were female, and 58% under 46. Of 338 receptionists in 180 fte posts (headcount:fte ratio 1:1.9), 98% were female, and 61% under 46.
23 North East and North Cumbria Dental Workforce Survey, 2016
4.6 Skill-mix and services provided
We also considered the potential skill-mix of dental teams in the region. The questionnaire asked about numbers of nurses with more specialised nursing qualifications and DCPs who undertake additional duties. Since the earlier ‘Northern Deanery’ survey, changes in GDC regulations relating to registrants’ scope of practice, has meant that certain defined skills can (with additional training and if competence and indemnified), be performed by certain GDC registrants 23.
Further qualifications
There were 197 (18%) nurses listed by dental practice respondents as being ‘extended duty’ dental nurses (EDDNs). The number of dental nurses in training or qualified to provide some specific examples of additional duties are summarised in table 7. The most common additional qualifications (with examples taken from the National Examining Board for Dental Nurses – NEBDN) were in dental radiography, sedation nursing and oral health education, with relatively few taking dental implant, orthodontic or special care nursing qualifications. These data were not gathered in 2006/7 and the impact on local practice delivery and implications for training in the region merit further discussion.
Table 7. Number of additional qualifications held by dental nurses in primary care.
Activity Number qualified Number in training % of sample who have or are in training for qualification Dental Implant Nursing 41 11 5% Dental Radiography 147 15 15% Dental Sedation Nursing 120 9 12% Oral Health Education 119 15 12% Orthodontic Dental Nursing 18 3 2% Special Care Dental Nursing 6 0 1% The question did not specify if the qualification was currently being used by the dental nurse, so figures may not represent demand for nurse provision of services, but rather availability.
Delivery of services by dental care professionals
The activities that can be undertaken by DCPs following further training are defined in the GDC’s Scope of Practice document 23. The extent to which these are carried out is summarised in table 8. Appropriately trained nurses, therapists and hygienists were delivering these services in up to one third of practices across the region. The most common activities carried out by DCPs were taking radiographs, applying fluoride varnish to teeth, delivering oral health education, taking impressions, giving smoking cessation advice and measuring and recording plaque indices.
24 North East and North Cumbria Dental Workforce Survey, 2016
Table 8. Number of practices at which specific duties are undertaken by DCPs
Dental Dental Dental Nurse Clinical Dental Orthodontic Therapist Hygienist Dental Technician Therapist Technician Prescribe radiographs 12 (5%) 11 (5%) 5 (2%) 1 (0%) 2 (1%) 0 Take radiographs 44 (19%) 24 (11%) 47 (21%) 1 (0%) 1 (0%) 5 (2%) Apply fluoride varnish to teeth 61 (27%) 63 (28%) 44 (19%) 1 (0%) 2 (1%) 3 (1%) Deliver Oral Health Education 60 (26%) 77 (34%) 66 (29%) 2 (1%) 2 (1%) 5 (2%) Take impressions 48 (21%) 25 (11%) 38 (17%) 4 (2%) 2 (1%) 8 (4%) Give smoking cessation advice 53 (23%) 62 (27%) 26 (11%) 1 (0%) 2 (1%) 2 (1%) Measure and record plaque indices 60 (26%) 79 (35%) 11 (5%) 1 (0%) 2 (1%) 3 (1%) Administer inhalation sedation 3 (1%) 1 (0%) 0 1 (0%) 0 (0%) 0 Rubber dam 9 (4%) 3 (1%) 4 (2%) 1 (0%) 1 (0%) 0 Cannulation 0 0 1 (0%) 1 (0%) 0 0 Please Note: For some roles listed above, some of the duties listed may be outwith the relevant group’s GDC scope of practice. We suspect this may be user error (e.g. if the form was completed online or perhaps submitted by a non-clinical member of the dental practice team). However, all responses are included here for completeness.
Sixty-five practices reported that a mean of 65% of therapists' time was spent on activities associated with a hygienist's role, although there was a wide range – 2-100 percent (standard deviation 28.3). This may indicate the extent to which therapist and hygienist roles overlap, and this is not surprising considering similarities in many aspects of these groups’ GDC scopes of practice. The additional ability of dental therapists to be able to carry out direct restorations on primary and secondary teeth, to extract primary teeth, undertake pulpotomies and place pre- formed crowns on primary teeth, has been the subject of research into skill mix in dentistry and within the context of current NHS contractual regulations 24.
Specialised and specialist-delivered services
The questionnaire also identified what specialised services may be provided by primary care dentists. These are tabulated in table 9. The 'other' responses contributed few additions to the list, most of which referred to restorative or cosmetic services. Many of these responses may be based on legacy contracts, and hence associated with low actual frequency of these activities being carried out.
Table 9. Number of practices that reported delivering ‘more specialised’ services
Service Number of practices Implants 64 Orthodontic services 73 Minor oral surgery (excluding simple exodontia) 72 IV sedation 47 Inhalation sedation 24 Domiciliary care 70 Other 23
25 North East and North Cumbria Dental Workforce Survey, 2016
Forty-seven practices (21%) also indicated that they provided services from visiting specialists (dentists listed on at least one of the GDC’s specialist registers). Of these, the majority provided oral surgery, sedation and implants.
4.7 Vacancies, development and learning needs.
Free text areas within the questionnaire allowed practices to identify any current vacancies, and to list any development needs in their practice. Comments on potential plans for growth were also encouraged.
Regarding vacancies, just 28 (n=10%) practices completed a free text response. Of these, 17 indicated they were actively recruiting, or would like to recruit a dental nurse, four wished to advertise for a dental therapist, two practices a hygienist and six a dentist.
Fifty dental practices (n=22%) gave a free text response to the question: ‘Please list any development or learning needs that you have identified amongst your staff’. Although responses were varied, a number can be grouped and themed.
Dental Foundation Training. A small number of dental practices (n=5) wished to become training practices but experienced a range of barriers to being recognised in this capacity. Barriers reported included: pressure to meet unit of dental activity (UDA) targets and a lack of time to provide the necessary training; physical lack of space to accommodate a foundation dentist; and a lack of financial resource to support the process. Dental Nurse Training. Thirteen practices wanted to develop nurse training with appropriate ‘extended duties’ and qualifications in subjects such as sedation, radiology and implant nursing. Barriers identified by respondents included a need for more local courses and that UDA targets ‘made it difficult’ for practices (presumably due to time pressures and staffing issues). Desire to expand dental practices. A number of dental practices genuinely wished to expand but respondents (in all cases) said that the present NHS dental contract left no scope for growth or development due to NHS funding limitations. Local training courses. Specific suggestions for more local training courses were linked to the subjects of: smoking cessation; hands-on oral surgery; ‘customer service’ training for reception staff; oral health education training; team building and management and dental nurse implant courses. Several free text comments mentioned that dental teams did all of their CPD online.
26 North East and North Cumbria Dental Workforce Survey, 2016
5 Secondary Care
5.1 Background
Secondary care dental services are delivered in four sites across the region: Newcastle Hospitals NHS Foundation Trust, City Hospitals Sunderland NHS Foundation Trust, South Tees NHS Foundation Trust and North Cumbria University Hospitals NHS Trust. These units have a key training function as well as delivering Level 1 to 3 care. The levels of care (referred to in ‘NHS England’s ‘Introductory Commissioning Guide for Dental Specialties 2015’) have been designed to reflect procedural difficulty, patient modifying factors and competence required of a clinician to deliver care of that level of complexity 25.
In Northumbria Healthcare NHS Foundation Trust, secondary care services are provided by salaried dental care staff, outside of the Community Dental Services contract. These staff are included under the ‘salaried dental services section’. Other salaried dental services in the region may also deliver dental care in hospitals, but the scope of these activities is within respective salaried service specification.
5.2 Method
For the secondary care workforce and trainees in Dental Foundation or specialty training programmes, data were initially obtained from human resources (HR) departments, with contextual details obtained from Clinical Directors. Data from HR departments were obtained through a query to the Electronic Staff Record (ESR) system in use in all NHS Trusts. This returned data including the following fields:
Age group Gender Position Title Location – the site at which they are employed Ward /Department – the specific ward or department Staff Group – the type of job role, whether dental, medical, nursing Contract Hours – the number of hours or sessions contracted fte – the proportion of full-time contracted Assignment Category – the type of contract, whether permanent, fixed term or honorary Fixed Term Temp Cont End Date – the end date of fixed term contract
While some organisations provided full output from this query, one did not share individual-level data, but rather aggregate figures for each Position Title.
27 North East and North Cumbria Dental Workforce Survey, 2016
5.3 Results
The largest secondary care department is the Dental Hospital at Newcastle Hospital. The other sites are comparatively small. In Sunderland and South Tees, oral surgery and maxillofacial surgery are delivered within the same service area, and figures for both are included in the table. While not a dental specialty, maxillofacial surgeons do undergo undergraduate dental training, and so constitute a workforce destination for trainees.
Table 10 summarises the data obtained from the electronic staff record (ESR) systems at each employer. Figures are simplified to remove some of the variability in roles between sites, and reflect the different format in which data were provided by each employer. These figures do not include locum doctors or bank nurses.
Table 10. Summary of GDC-registered staff reported by secondary care Trusts.
Sunderland North Cumbria Newcastle South Tees Lead Total Employer Trust h/c fte h/c fte h/c fte h/c fte h/c fte h/c fte Consultant 6 6 5 (2 ortho, 3 5 34 (Inc. 14 6.35 7 6.6 NA - 52 23.95 oral surgery) honorary and 1 professor) Dental 4 4 None - 37 (inc 25 GPT, 12 37 None reported - 25 23 66 64 trainee reported dental trainee in hospital post) Other 7 (1 5.9 5 (1 dental 5 69 (8 Specialty 4.91 20 (10 specialty 13.4 NA - 101 29.21 dental Specialty SHO, 2 SHO, 2 doctor, 58 Trust doctor, 4 trust grades * doctor, 4 specialty grade dental doctor (SHO), 3 SAS doctor, doctor) practitioner, 3 trust grade 2 trust associate (Specialty grade) specialist) doctor), 1 Trust registrar, 2 dental SHO) Dental None - 9 7 119 (104 Band 4, 92.3 13 (inc 1 Lead 9.4 NA - 141 108.7 nurses (general 10 Band 5, 3 Tutor, Dental Nurse) nurses 2 Assessor) employed in department) Dental None - 5 (1 dental 0.72 23 (4 senior, 4 21.8 3 2.5 NA - 31 25.02 technician reported technician 'highly specialist', 9 advanced, 4 Band 5, 6 Band 7) medical dental technician bands 4-8a) Dental None - None - 13 (2 principal 5.5 None reported - NA - 13 5.5 therapists reported reported hygienist/therapist, and 2 tutor hygienists hygienist/therapist, 4 tutor hygienist) Figures exclude locum and bank staff, but do include fixed term temporary posts and honorary consultants. Also excluded are general nurses registered with the Nursing and Midwifery Council, health care assistants and laboratory/technical staff. * 'Other dental grades' include posts described as SHO, Registrar, Trust doctor, Specialty doctor and similar.
Across all staff groups in the three trusts where individual data on sex and age were provided, there are more women than men (n=58, 63%), largely because all dental nurses reported are female. Among non-consultant
28 North East and North Cumbria Dental Workforce Survey, 2016 dentists there is more of a balance (19 female to 13 male), but among consultants the pattern is reversed, with 14 of 18 consultants being male.
Of the 25 trainees employed by the Lead Employer Trust (LET), 21 are full-time. Fifteen are female and ten male. Eleven are on three year pre-CCST training programmes, five on five-year programmes, and four on post-CCST programmes. Three are NIHR trainees and two LAT posts. Eleven are due to complete training in 2016 and eight in 2017.
29 North East and North Cumbria Dental Workforce Survey, 2016
6 Salaried Dental Services
6.1 Background
Community-based salaried dental services complement primary and secondary (hospital) care services by providing NHS treatments, which often have a specialised component for patients with additional, complex or special needs. These services also have dental public health functions including dental epidemiology and survey monitoring of the oral and dental health status of local populations.
Patients include children, adults and the elderly, those with medical co-morbidities restricting dental treatment, physical disabilities, significant learning difficulties or dental anxiety/phobia. Accordingly, salaried dental practitioners work closely with a wide range of professionals across health and social care services. Referrals to the community service may come from general dental practitioners, secondary care dental services, general medical practitioners and other health professionals.
Services are delivered through an NHS organisation – most often in the community setting – and are led by a Clinical Director.
6.2 Method
In this region there are six salaried dental services (table 11). While the scope of services may be similar, the management and delivery of each service may differ. Hence, while the primary care questionnaire was used as a basis for data collection, further discussion was held with the respective Clinical Director/HR representatives to capture nuances of service structure and/or delivery.
Table 11. Summary of Salaried Dental Services
Service Locality / sites Cumbria Partnership NHS Foundation Trust Clinics in 10 sites Carlisle & Eden locality Furness & South Lakes -Westmorland General Hospital Allerdale / Copeland – Workington Community Hospital) Newcastle Upon Tyne Hospitals NHS Foundation Trust Clinics in 4 community sites (Arthurs Hill; Kenton; Walker; Byker) Northumbria Healthcare Foundation Trust Clinics in health centres (7) across Northumberland & North Tyneside; also, Wansbeck Hospital & Hexham Hospital. (also, also delivers some secondary care GA services out with the PDS arrangement' [see secondary care, 5.1]) North Tees NHS Foundation Trust Clinical care delivered in 5 locations. Also, oral health promotion team, who provide education only to commissioned patient groups and carry out the public health aspects of the service. County Durham & Darlington Foundation Trust Multiple sites South Tyneside Foundation Trust Gateshead, Sunderland and South Tyneside Clinics in 3 hospitals, 1 community hospital and 5 health centres.
30 North East and North Cumbria Dental Workforce Survey, 2016
6.3 Results
The salaried services have locality teams, but delivery is characterised by flexibility whereby staff may move between centres within a locality, or even between localities, according to service need.
Data here are presented for the whole of the salaried sector, but with commentary highlighting how organisation and delivery may vary across the region, which may have consequences for the relative proportions of occupational groups.
Staff profiles – Dentists
The salaried services employed a total of 107 dentists, of whom 29 were full-time (working at least 37.5 hours), with 70 fte posts overall (table 12). This figure included some posts where the staff member was currently on long-term leave (eg, maternity or sick leave) and where posts may be temporary.
Table 12. Summary of dentist posts across salaried dental services
Headcount fte Full-time staff Cumbria 38 25.3 9 Teesside 7 6.2 4 Northumbria 17* 12.0 5 Newcastle 14 6.3 3 S Tyneside 16 11.4 6 Durham & Darlington 15 8.3 2 Total 107 69.5 29 * Includes professional lead with no clinical commitments and academic dentist with honorary clinical contract
The majority of these dentists were female (79, 74% of those where sex is known) and in the 30-45 age group (49, 46% of those where age is known).
The distribution of working hours is given in figure 11, and the breakdown of full- and part-time dentists by demographics is given in figure 12. The figures show that 50% of all salaried dentists worked at least 26 hours per week. Less-than-full time working was more common among female salaried dentists, with 76% (n=58) working part-time compared to 61% (n=16) of men.
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Figure 11. Distribution of working hours for salaried dentists.
Figure 12. Frequency of full- and part-time salaried dentists by age and sex.
Four services indicated that they provided specialist-delivered services. These were special care dentistry (Cumbria, Durham and Darlington, and Newcastle), paediatric dentistry (Durham and Darlington) and orthodontics (Northumbria).
The majority of dentists qualified in the North East, although the proportion was less than those working in primary care (56, 52.3%). Forty-one dentists (38.3%) qualified elsewhere in the UK, with four dentists (3.7%) qualifying elsewhere in Europe.
Staff profiles – Dental Nurses and Dental Care Professionals
There were 128 dental nurses reported to be working across the services, all but one of whom were female, and 65% of whom were under 46 years old. This group constituted 46% of the salaried workforce. Numbers of other
32 North East and North Cumbria Dental Workforce Survey, 2016 staff groups were low, with just 6 dental therapists, four dental hygienists and two dental technicians. There were no clinical dental technicians or orthodontic therapists reported. Table 13 summarises the figures for registered dental care professions. One student dental nurse was also recorded by one service.
Table 13. Summary of registered Dental Care Professionals in salaried dental services*
Job Headcount fte Headcount: % female % under 46 % qualified in North fte ratio East England Dental nurse 128 95.5 1.3 99% 65% 70% Dental therapist 8 3.5 2.3 100% 17% 50% Dental hygienist 6 3 2 100% 60% 0% Dental technician 2 2 1 0% 50% 50% *Salaried services also had oral health promotion staff who had a dedicated educational role. As these data were not available for all services, they have not been included in the table above.
Administrative staff
There were a number of administrative staff employed across the salaried sector – three (1.6 fte) practice managers, and a total of 24 (15.1 fte) other administrative staff, including receptionists. Of these, 88% were female and 36% under 46.
Skill mix and services provided in salaried dental services
Thirteen dental nurses (10.1%) were identified by respondents to the questionnaire as being extended duties dental nurses (EDDNs). The numbers of nurses with, or in training for, additional National Examining Board for Dental Nurses (NEBDN) qualifications are summarised in table 14.
Table 14. Number of additional qualifications (NEBDN) held by dental nurses in salaried dental services.
Activity Number qualified Number in training % of sample who have or are in training for qualification Dental Implant Nursing 0 0 0% Dental Radiography 34 0 27% Dental Sedation Nursing 81 3 66% Oral Health Education 29 0 23% Orthodontic Dental Nursing 4 0 3% Special Care Dental Nursing 13 1 11% The question did not specify if the qualification was currently being used by the dental nurse, so figures may not represent demand for nurse provision of services, but rather availability.
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Table 15 summarises the activities undertaken by DCP staff across the salaried services. The activities undertaken by these groups are similar to those carried out in primary care. Radiograph prescribing was not carried out by dental hygienists or dental therapists, despite this skill being listed in their scope of practice (if suitably trained, competent and indemnified).
Table 15. Specific ‘additional duties’ undertaken by DCPs in salaried dental services
Dental Dental Dental Nurse Therapist Hygienist Prescribe radiographs Take radiographs x x x Apply fluoride varnish to teeth x x x Deliver Oral Health Education x x x Take impressions x x Give smoking cessation advice x x x Measure and record plaque indices x x Administer inhalation sedation x Rubber dam x
Respondents indicated that on average 43% (sd 25%, and a range of 0-75%) of a therapist’s time was spent performing hygienist activities.
Vacancies, training and development needs
There were relatively few vacancies in the salaried services. Across all services there was a shortfall in two full-time and two part-time dentists, four full-time dental nurses (all nursing bands), one full-time dental therapist and three administrative staff (receptionist, practice manager and administrator).
Several areas for training and development were identified in free text. The most common suggestion was a need for training in special care dentistry. Other learning needs cited were sedation, epidemiology calibration, clinical holding, oral health education and cannulation.
Also, clinical pressures were reported that could influence training priorities. These included the need to have skills to cope with the high volume and complexity of the ageing population with rising prevalence of dementia. Also, the need to manage an increase in the number of referrals of patients for dental anxiety issues.
One of the respondents listed a need for additional training of administrative staff to develop their communication and time management skills. Other training needs identified by individual respondents were: training in Immediate Life Support and Paediatric Immediate Life Support; leadership training for those in senior roles; training in minor oral surgery skills; use of dental management software; oral health education and smoking cessation; development of IV sedation to be delivered by qualified dental staff rather than anaesthetists, and alcohol awareness training.
34 North East and North Cumbria Dental Workforce Survey, 2016
Notably, funding was listed as a barrier to appointing specialists in Special Care Dentistry, while time was raised as an issue for nursing staff attending CPD sessions.
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7 Prisons
At the time of the 2006/7 Northern Joint Dental Workforce Group report, Primary Care Trusts (PCTs) had responsibility for the local commissioning of prison dental services. However, since April 2013, NHS England has directly commissioned dental services for persons who are detained in prison or in other secure accommodation. A core function of commissioning is to provide consistent high quality services across England that meet national standards and local needs.
There are six prisons in the North East (including one women’s prison and one young offender institution). These are summarised in table 16.
Table 16. Details of locations of delivery of prison dental services across the region
Region Name Prison Category status North East Frankland A North East Low Newton (women) A North East Holme House B North East Northumberland B North East Durham B North East Deerbolt Young Offender Institution North Cumbria Haverigg C
The current provider employs dentists, dental nurses and therapists to deliver the service across all of the region’s prisons. Prison dentistry poses well-recognised clinical and service challenges. These include poor oral health, often compounded by drug abuse, a high number of non-attendances, incomplete and complex courses of treatment, all of which have implications for meeting the terms of a UDA-based payment system. Hence, while the provider is commissioned under a Personal Dental Services (PDS) contract, individual staff are employed on a sessional basis. Dentists and therapists working in the prison service also work in primary care, but the dental nurses are employed only in the prisons.
7.1 Data collection tool
The primary care questionnaire was adapted for use in the prison setting. It covered the following areas:
Number of dentists; demographics & pattern of working (hours / days). Number, demographics and hours of working of other staff groups (dental therapists; dental hygienists; GDC registered dental nurses; dental nurses in training). Place of primary qualification and additional qualifications for all staff groups. Activities performed by dental care professionals Specialised services offered by dentists
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Free text comment – including suggested development or learning needs.
The questionnaire was completed by the two site managers (one for Cumbria; one for the North East cluster), with clarification and additional contextual information supplied by a senior manager within the contract holding organisation.
7.2 Staff profiles
Dentists
There are eight dentists working in the seven North East and North Cumbria prisons (which include one Young Offender Institution). These dentists all work both in primary care practice and prison services, and have an average of 7.25 hours per week in the prison (range 6-9 hours). Most dentists are women (6 of 8), and all are aged under 46 years.
These data are in keeping with those of a 2014 national survey of prison services in England and Wales 26. In that report, two thirds of dentists worked between two and four sessions per week and half were the sole dentist in a prison surgery.
Other staff
Prisons have a dedicated GDC registered dental nurse (x6) or dental nurse in training (x1) and a dental therapist, but there are no dental hygienists (however, dental therapists provided hygiene services). Each prison has only a single nurse and therapist, which is broadly similar to the findings of the 2014 national report where 55% of prison surgeries had just one nurse. Of the nurses, two are identified as providing ‘extended duties’ and one of these provided dental activities across the North East prison cluster. A manager supported each of the services (1 fte for the North East prison cluster; 1 fte for North Cumbria).
Nurses work an average of 27.2 hours per week (range 9-39 hours). All are female, qualified in the North East and all are aged under 46 years.
Therapists, who also work in primary care practices, work an average of 7.5 hours per week (range 3-8 hours). Again, the majority (6 of 7) are female, aged under 30 years (5 of 7) and all qualified in the North East.
7.3 Dental care practitioner activities and specialised services
At all prisons either a dental nurse or therapist are able to provide the following services: taking radiographs, applying fluoride varnish, delivering oral health education, measuring and recording plaque indices and giving smoking cessation advice. Also, therapists, in all but two prisons, took impressions. Activities not carried out by
37 North East and North Cumbria Dental Workforce Survey, 2016
DCPs in any prison (according to respondents of the prison questionnaire) were prescribing radiographs, administering inhalation sedation or applying rubber dam.
None of the prison settings reported that they had a visiting specialist, nor that they offered other specialised services (including orthodontic services, inhalation sedation or minor oral surgery (excluding simple exodontia).
No training needs were identified in free text. However, the provider indicated that dental staff valued the opportunity and the clinical challenges presented by the prison population. Further training courses in oral health education, fluoride application and smoking cessation were welcomed.
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8 Educational institutions
Data were also gathered from local colleges and universities that offer dentist and/or dental care professional courses, since GDC-registered dentists and other GDC-registered DCPs are heavily involved in teaching students at a range of different educational levels.
Data were obtained from a variety of sources, including the institutions’ websites and telephone discussions with course leads (or nominated deputies). Staff were asked about the number and demographics of GDC-registered professionals who taught on their programmes.
8.1 Results
In considering the information provided, we have divided educational providers into those providing ‘Further Education’ (typically Colleges providing dental nurse courses) and ‘Higher Education (typically Universities providing training for future dentists and dental hygienist/therapists).
Within the North East and North Cumbria, Further and Higher Education training for dental care professionals is delivered by six institutions (table 17). Additionally (not shown in table 17), Newcastle University offers a number of postgraduate training courses for qualified dentists including Diplomas in Conscious Sedation and Clinical Implant Dentistry, MClinDent in Restorative Dentistry and MSc in Orthodontics.
Table 17. Summary of undergraduate/pre-registration dental training courses within North East England and North Cumbria.
Institution / Provider Course/s available Level of Award Course Duration Newcastle University BDS(Hons) Bachelor of Dental Surgery Undergraduate Degree 5 years, FT (dentist) BSc(Hons) Oral and Dental Health Undergraduate Degree 3 years, FT Sciences (hygienist & therapist) Newcastle Dental Hospital Dental Nursing Level 3 Diploma 18-24 months, PT (1 day per week) Dental Technology (in conjunction with Pearson BTEC 3 years, FT Leeds Dental Hospital) Teesside University BSc(Hons) Dental Hygiene and Dental Undergraduate Degree, 3 years, FT Therapy Certificate in Higher Cert HE in Dental Nurse Practice Education 1 year, FT New College Durham Advanced Apprenticeship Dental Nursing Level 3 Advanced 18 months, PT (1 day Apprenticeship per week) Newcastle College Dental Nursing Apprenticeship Apprenticeship Not provided Sunderland College Get Ready for…Dental Nursing Level 2 course 6 weeks, PT Dental Nursing Diploma Level 3 Diploma 1 year, FT/PT Carlisle College Dental Nursing Level 3 Diploma 2 years, PT
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8.2 Dentists
The Bachelor of Dental Surgery (BDS) degree programme is delivered by the School of Dental Sciences at Newcastle University. The five year programme recruits approximately 70 students per year (subject to Department of Health quota which fluctuates annually) from around 600 applicants, and teaching is delivered by a range of academics, dental care professionals and scientific teachers. With respect to the clinical dental workforce at Newcastle, only those staff who are employed by Newcastle University are listed in table 18 along with a break down by sex and full- time equivalency. An important caveat when interpreting table 18 is the fact that there are many additional NHS- employed clinical staff who teach at an undergraduate level but their data do not appear here. This is because they are employed directly by the NHS (although many will hold an Honorary academic contract with Newcastle University). These individuals will have been captured for the purposes of this survey through secondary or primary care samples.
Table 18. GDC-registered clinical academic staff employed directly by Newcastle University and linked to undergraduate teaching.
GDC-Registered GDC-Registered Total Male staff Female staff Clinical academic* role descriptor: Number fte Number fte Number fte Teaching Fellow 0 0 2 2.0 2 2.0 Clinical Fellow 3 2.8 6 4.85 9 7.65 Lecturer 2 2.0 3 3.0 5 5.0 Senior Lecturer 3 3.0 1 1.0 4 4.0 Clinician Scientist 2 2.0 0 0 2 2.0 Professor 6 6.0 2 1.8 8 7.8 Total 16 15.8 14 12.65 30 28.45 *Only those directly employed by Newcastle University. (No attempt has been made to list Honorary NHS positions for these staff).
8.3 Dental Nursing
Dental nursing courses are offered at six locations in the region: Newcastle Dental Hospital, Teesside University, New College Durham, Newcastle College, Sunderland College, and Carlisle College. Teesside University offers a Certificate in Higher Education Dental Nurse Practice, while the three Further Education colleges offer the City & Guilds Level 3 Diploma in Dental Nursing. All programmes are similar with training taking place mainly in practice placements, with one day a week spent in the classroom. The size and staffing of these and other non-BDS courses is illustrated in table 19.
Numbers of staff teaching at the colleges are relatively small with two or three dental nurses at each location (nine in total) and one dental therapist at Sunderland College. Teesside University employs one dental nurse, alongside seven therapists and three hygienists.
40 North East and North Cumbria Dental Workforce Survey, 2016
At Newcastle Dental Hospital, a Diploma in Dental Nursing (City & Guilds) is currently available. The course lasts between 18 and 24 months with a maximum of 24 places. There is one full-time member of staff leading and co- ordinating the programme who is supported by a number of part-time tutors, eight part-time assessors and three internal quality assurers (IQAs). In addition to the dental nursing diploma, Newcastle Dental Hospital additionally offers post-qualification courses in special care and sedation dental nursing (n=12 places on each course).
Table 19. Summary of places available on undergraduate dental training courses and indicative staffing (excluding BDS at Newcastle University)
Institution Course Number of students Staff numbers / fte Newcastle University BSc(Hons) in Oral & Dental 10 3.78 fte (+ other clinical Health Sciences academics) Newcastle Dental Hospital Level 3 Dental Nursing 24 1/full-time 4/part-time Pearson BTEC Dental 4 1/full-time Technology Teesside University BSc(Hons) – Dental Hygiene 12 5-full-time and Dental Therapy Cert HE in Dental Nurse 16 5-full-time Practice New College Durham Level 3 Advanced 35 1/full-time Apprenticeship 1/part-time Newcastle College Dental Nursing Apprenticeship 40 2/full-time Sunderland College Get Ready for…Dental Nursing No limit (year round Dental Nursing Diploma acceptance) 4/full-time 23 Carlisle College Level 3 Dental Nursing 20 2/part-time * Please note. The indicative number of places per course and associated staffing numbers are liable to fluctuate.
8.4 Dental Therapist and Hygienists
Dental therapists and hygienists are trained at Teesside University (on the BSc Dental Therapy and Dental Hygiene) and Newcastle University (BSc in Oral and Dental Health Sciences – ODHS). These are three-year programmes. The Newcastle BSc degree programme recruited its first intake in September 2015.
At Newcastle, for which information was available, the three-year BSc in ODHS is associated with one full-time Principal Tutor, and part time staff in the form of a General Dental Practitioner (0.4 fte), Hygienist Tutors (1.27 fte) and Therapy Tutors (1.11 fte) employed by Newcastle Hospitals Foundation Trust with associated income from HEE.
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9 Discussion
This survey provides a snapshot of the dental workforce across North East England and North Cumbria. While any estimates of the full scale of the workforce must be tentative, the sizeable response rate and figures proportional to national and regional GDC registrants suggest some extrapolation is valid.
The primary objective was to provide current data on the structure of the region’s dental workforce. Key observations are based around several areas – the professional composition of the workforce, the demographics of the workforce and the organisational/service sector. These are summarised below.
Workforce composition
As we might expect, the majority of the dental workforce are in primary care, and this sector appears to have grown since a comparable survey (with similar response rate) was carried out in 2006.
Dental nurses are the largest group within the workforce by headcount and represent 38% of the total primary care workforce. While therapists and technicians form a small part of the primary care workforce, their numbers in particular have grown substantially over the last 10 years.
Around 20% of dental nurses in primary care currently are listed as an Extended Duty Dental Nurse and up to one third of practices report nurses or dental care professionals undertake a number of skills listed on the GDC Scope of Practice that were previously the remit of dentists alone.
Demographics
In 2006-7, a risk of attrition from an ageing dentist workforce was identified. This does not appear to be happening, as the proportions of dentists in the older age groups are broadly similar to the earlier data, and indeed the peak number of dentists are in the younger age bands (<46 years) across the sectors surveyed.
Notably, the majority of dental nurses tend to be young (<46 years) and particularly so in the primary care sector, where 89% of nursing staff were under 46 years of age. This raises a question as to why older, and ostensibly more experienced, nurses are lost to the workforce and what the service implications may be.
In primary care, there has been a gender shift, with younger dentists more likely to be female. In salaried services and prison dentistry, female dentists predominate.
Sector factors
Dentists are delivering a large amount of NHS care, but the proportion of private work performed in a practice appears to be increasing. We speculate that this may reflect a number of hygienists, therapists and/or visiting specialists who are also carrying out private treatments.
42 North East and North Cumbria Dental Workforce Survey, 2016
Working patterns
Seven-day working across the workforce is minimal, with less than 20% of primary care practices open on Saturdays, and only one on Sundays.
Notably, part-time working is commonplace in primary and salaried sectors. In primary care the proportion of dentists working part-time appears to have increased significantly since 2006 (now only 14.7% working full-time), and especially amongst males and younger dentists. One reason for this finding may be that more dentists are perhaps working in more than one practice. However, the explanation and implications of the observation for practice’s service models merits further detailed discussion with stakeholders.
Development needs
A secondary objective was to identify training opportunities or gaps that may support HEE in reviewing the local programme of education and training.
While free text responses was generally limited, specific training needs listed in primary dental care included training in the subjects of: smoking cessation; hands-on oral surgery; ‘customer service’ training for reception staff; oral health education; team building and management and dental nurse implant courses (although this list is not exhaustive). The changing clinical profile and patients’ oral health needs were noted by the salaried sector: future more detailed discussion, taking account of the clinical context, may well reveal further training opportunities that can address specific challenges in local practice. Some areas for development might be inferred from the survey data, which show that additional nursing qualifications and DCP’s full scope of practice were not always being used to their full potential. This may be because changes to certain registrants’ scope of practice have only occurred in relatively recent years. The reasons underpinning availability and/or uptake of training opportunities are not explored in this work and further qualitative data are needed to understand the individual and service drivers to additional training. This information may guide planning of training programmes, which could enhance the skill-mix and support service delivery. We did not explicitly ask about the use of electronic communication (including online learning) in this survey. However, the very low uptake of the online survey tool, while it may simply mean that people prefer to complete paper questionnaires, also suggests the possibility that dental practices may not be as connected (electronically) as some other areas of healthcare.
10 Areas of future work
While the survey findings describe the current structure of the workforce in North East England and North Cumbria, there is now opportunity to establish how this structure relates to service delivery in practice and to patient care needs and expectations in the region.
43 North East and North Cumbria Dental Workforce Survey, 2016
Specific questions the survey raise are:
1. How are other Dental Care Professionals with additional qualifications and/or extended skills used in service delivery? How can use of skill-mix be optimised?
2. What are the factors that influence retention of dentist and non-dentist staff in the workforce?
3. How do current working practices – especially increased part-time and/or flexible working – impact on service models?
4. In what way may patients’ oral health needs and expectations in the region further inform workforce planning and shape a strategy for education and training?
44 North East and North Cumbria Dental Workforce Survey, 2016
References
1 Birch, S. Health human resource planning for the new millennium: inputs in the production of health, illness, and recovery in populations. The Canadian journal of nursing research, 2002; 33: 109-114. 2 Northern Joint Dental Care Workforce Group. Primary Care Dental Workforce Survey of the North East. NHS North East, 2007 3 Steele, J., NHS Dental Services in England. London: Department of Health, 2009. 4 Holmes, RD, et al., Learning from contract change in primary care dentistry: A qualitative study of stakeholders in the north of England. Health Policy, 2015; 119: 1218-1225. 5 Brocklehurst, P & Tickle, M. Planning a dental workforce for the future for the National Health Service in the United Kingdom: What factors should be accounted for? Health Education Journal, 2012; 71: 340-349 6 LaingBuisson. Dentistry UK Market Report 2014. [Available from https://www.laingbuisson.co.uk/Portals/1/MarketReports/Documents/Dentistry14_brochure_WEB.pdf] 7 Chestnutt, IG, Davies, L & Thomas DR. Practitioners' perspectives and experiences of the new National Health Service dental contract. British Dental Journal, 2009; 206: E18-E18. 8 Harris, R, et al. Job satisfaction of dental practitioners before and after a change in incentives and governance: a longitudinal study. British Dental Journal, 2009; 207: E4-E4. 9 Mills, I & Batchelor, P. Quality indicators: the rationale behind their use in NHS dentistry. British Dental Journal, 2011; 211: 11-15. 10 HMSO. Health and Social Care Act 2012. 11 NHS Commissioning Board. Securing excellence in commissioning NHS dental services. London: NHS Commissioning Board, 2013. 12 General Dental Council. Standards for the Dental Team. London: GDC, 2013 13 Centre for Workforce Intelligence. A strategic review of the future dentistry workforce. www.cfwi.org.uk 14 Department of Health. Report of the Primary Care Dental Workforce Review. Department of Health, 2004 15 Gallagher, JE, Patel, R & Wilson NHF. The emerging dental workforce: long-term career expectations and influences. A quantitative study of final year dental students' views on their long-term career from one London Dental School. BMC Oral Health, 2009; 9: 1. 16 British Dental Association. State of Salaried Dentists 2013. 17 Enventure Research. Annual Survey of Registrants 2013. Research Report for the General Dental Council 2014 18 NHS Education for Scotland. Dental Workforce Report, December 2014. 19 National Leadership and Innovation Agency for Healthcare. Analysis of Dental Workforce 2012. 20 McColl E, Jacoby A, Thomas L, Soutter J, Bamford C, Steen N, et al. Design and use of questionnaires: a review of best practice applicable to surveys of health service staff and patients. Health Technology Assessment 2001; Vol. 5: No. 31 21 Watt, S, Simpson C, McKillop C & Nunn V. Electronic course surveys: does automating feedback and reporting give better results? Assessment & Evaluation in Higher Education 2002; 27: 325–337. 22 BDA Business Trends Survey 2012. Accessed online at https://www.bda.org/dentists/policy-campaigns/research/workforce- finance/gp/Documents/business_trends_report_2012.pdf on 24.05.2016 23 General Dental Council 2013. Scope of Practice. [Available online at: https://www.gdc- uk.org/Dentalprofessionals/Standards/Documents/Scope%20of%20Practice%20September%202013%20(3).pdf. Accessed on 24.05.2016.] 24 Brocklehurst PR and Tickle M. Is skill mix profitable in the current NHS dental contract in England? British Dental Journal 2011; 210: 303-308 25 NHS England. Introductory Commissioning Guide for Dental Specialties 2015. Accessed online at: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/09/intro-guide-comms-dent-specl.pdf on 24.05.2016.
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26 Patel R, Wright D, Railton C & Canty A. A survey of dental services in adult prisons in England and Wales. Public Health England, 2014
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Appendices
Appendix A. Primary Care Questionnaire
Appendix B. Summary of questionnaire returns over time
Appendix C. Comparison with national and regional GDC registrations
48 North East and North Cumbria Dental Workforce Survey, 2016
Appendix A – Primary Care Questionnaire
Dental Workforce Survey March 2016 Planning and developing the dental workforce of the future. The Practice Manager If you would prefer to complete the survey online, please «Practice_Name» go to www.tinyurl.com/DentalWorkforce2016 and enter «Address_1» this code when asked: «Q_ID» «Address_2» If you have any queries, please contact «Address_3» [email protected] «Postcode» Dear Colleague Newcastle University Dental School and School of Medical Education are undertaking a study of the private and NHS dental workforce across North East England and North Cumbria. This work will allow those responsible for commissioning the training of all dental healthcare professionals to plan for the workforce needs of the future, in private as well as NHS sectors. The questionnaire should be completed with staff numbers for the whole practice based at the location named below (if part of a partnership or group, each location should return a questionnaire). Please correct any details of practice name or address before returning. The enclosed FAQ provides more details of why some of this information is being collected. Your participation in this work is very much appreciated. Yours sincerely,
Richard Holmes Gillian Vance Senior Lecturer/ Clinical Senior Lecturer Hon Consultant in Dental Public Health School of Medical Education Newcastle Dental School
Person completing survey Name: ______Please give these details so we can contact you in the Position: ______unlikely circumstances that we require clarification. Contact email: ______Contact number: ______
Does this practice treat patients: Is this practice independent or a member of a corporate/group provider? ⃝ Exclusively privately ⃝ Exclusively NHS ⃝ Independent (single owner) ⃝ A mixture of private and NHS; ⃝ Independent (partnership) please give approx. % NHS: _____ ⃝ Corporate/group (please specify which) ______
49 North East and North Cumbria Dental Workforce Survey, 2016
Staff numbers To plan the workforce requirements of the future, it is important to know the demographic composition of the current workforce – both private and NHS. For each of the groups below, please complete the requested information.
Dentists How many dentists work in your practice location? _____ For each dentist, excluding any visiting specialists, please give the following details. (If more than fifteen, please continue on the back of the questionnaire).
Which days are usually worked? Sex Age group: Normal Approx. % Mon Tue Wed Thu Fri Sat Sun Is this a 1 – Under 30 weekly NHS Foundation 2 – 30-45 hours workload dentist 3 – 46-55 (please 4 – Over 55 tick) Dentist 1 Dentist 2 Dentist 3 Dentist 4 Dentist 5 Dentist 6 Dentist 7 Dentist 8 Dentist 9 Dentist 10 Dentist 11 Dentist 12
Dentist 13
Dentist 14 Dentist 15
Please list any additional postgraduate qualifications held by dentists working in this practice (eg MSc, MFDS, MJDF)
How many visiting specialists attend this practice location?
Which services do they provide and how often?
50 North East and North Cumbria Dental Workforce Survey, 2016
Other staff In the following tables, please complete the requested information for each staff group. If there are no staff in a given group, please write ‘None’ in the top row.
a) Dental therapists b) Dental hygienists c) GDC registered d) Dental nurses in dental nurses* training Male Female Male Female Male Female Male Female Number of staff Total hours worked in this location (approx.) Number aged under 30 Number aged 30-45 Number aged 46-55 Number aged over 55 * Excluding qualified dental nurses whose main role is in another job – eg practice manager or receptionist.
e) Clinical dental f) Dental g) Orthodontic h) Practice i) Receptionists technicians technicians therapists managers Male Female Male Female Male Female Male Female Male Female Number of staff Total hours worked in this location (approx.) Number aged under 30 Number aged 30-45
Number aged 46-55 Number aged over 55
How many of the dental nurses in this practice counted in c) above also regularly have other roles in the practice (eg reception or practice manager – not counting ad hoc sickness cover etc.)?
Is the practice manager a qualified dental professional? ⃝ Yes ⃝ No
Please list any current vacancies in any of the above staff groups.
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Place of primary dental qualification We would like to know how much of the local workforce qualified locally and elsewhere. Please enter the numbers of staff in each group who obtained their primary dental qualification in each area.
Qualified in North Qualified elsewhere Qualified elsewhere Qualified Not East England in the UK in the European elsewhere in the known Economic Area* world Dentists Dental therapists Dental hygienists Dental nurses Clinical dental technicians Dental technicians
Orthodontic therapists * Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Norway, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden or Switzerland.
Dental nurse qualifications For these questions, ‘dental nurses’ includes all qualified nurses in the practice, even if their primary role is in another job. How many dental nurses in this practice location have or are in training for the following primary dental qualifications?
Have qualification In training
National Examining Board for Dental Nurses (NEBDN) National Diploma in Dental Nursing City and Guilds NVQ Level 3 diploma in Dental Nursing Certificate of Higher Education in Dental Nursing
How many dental nurses working at this practice location are qualified as Extended Duties Dental Nurses (EDDNs)?
How many dental nurses in this practice location have or are in training for the following specialised NEBDN qualifications? Have qualification In training
Dental Implant Nursing Dental Radiography Dental Sedation Nursing Oral Health Education Orthodontic Dental Nursing Special Care Dental Nursing
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Activities performed by different staff groups Please tick which of the following activities are undertaken by the following staff groups at any time in this practice location? Please consult with the Principal Dentist or Practice owner to complete this table if necessary. Dental Dental Dental Nurse (including Clinical Dental Orthodontic Therapist Hygienist joint receptionist or Dental Technician Therapist practice manager roles) Technician Prescribe radiographs Take radiographs Apply fluoride varnish to teeth Deliver Oral Health Education Take impressions Give smoking cessation advice
Measure and record plaque indices Administer inhalation sedation Rubber dam Cannulation
Approximately what proportion (as a percentage) of dental therapists’ time is spent performing hygienist activities or competencies?
Which of the following specialised services are offered by dentists in this practice location (please tick)?
Implants IV sedation Orthodontic services Inhalation sedation Minor oral surgery (excluding simple exodontia) Domiciliary care Other (please specify)
Please list any development or learning needs that you have identified among your staff. For example, if relevant, what might encourage you to become a foundation training practice? Please identify as much detail as you think is relevant.
Finally, please add any other information that may help us interpret the shape and needs of the dental workforce. For example, what growth or future employment plans may you have in the practice?
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Thank you for completing the questionnaire.
Question 4 continuation table
Which days are usually worked? Sex Age group: Weekly Approx. % Mon Tue Wed Thu Fri Sat Sun Is this a 1 – Under 30 hours NHS Foundation 2 – 30-55 workload dentist 3 – Over 55 (please tick) Dentist 16 Dentist 17
Dentist 18 Dentist 19 Dentist 20 Dentist 21 Dentist 22 Dentist 23 Dentist 24 Dentist 25
The Dental Workforce Survey 2016 is conducted by Newcastle University. All data will be held securely at Newcastle University. A report containing aggregated anonymous data will be provided to Health Education England.
54 North East and North Cumbria Dental Workforce Survey, 2016
Appendix B – Data collection and return rate for primary care questionnaire
The rate of return of paper and online questionnaires is displayed below, with arrows indicating reminders. This shows a rapid response from many practices, but that the reminder contacts did elicit substantial numbers of additional responses. Overall, 50% of responses were received in the first 15 days, whereas it took another 29 days to reach 75% of all returns.
55 North East and North Cumbria Dental Workforce Survey, 2016
Appendix C: Comparison of responses with General Dental Council registration data
Data were obtained from the GDC on numbers of registered professions in postcodes across the region, with the exception of TD which is predominantly covers the Scottish Borders.
These do not provide an absolute figure of staff within the catchment area, as the registered address is often a home address, and people may work outside of the region (this is particularly true of the CA postcode which has relatively few population centres but is close to south Cumbria and the greater north west, and TS, which borders North Yorkshire. The DL postcode also straddles the North East and North Yorkshire boundary.
Registrants will also include staff working in all sectors, whereas our sample data are drawn from primary care respondents only.
These caveats aside, these figures give an approximation of the likely number registered dental professionals in the area, and so the extent to which our respondents may be representative.
Numbers of staff
The proportions of different staff groups represented in our sample vary. While 50% of dentists and 55% of hygienists reflect our response rate by practice, other professions show greater variation – from just 6% of dental technicians to 67% of clinical dental technicians and 91% of orthodontic therapists registered in the region are represented in our sample.
Dentists Nurses Therapists Clinical Hygienists Dental tech Orth dental therapists technicians GDC 1567 2751 123 15 274 276 23 Sample 783 1057 97 10 152 18 21 % of GDC 50 38 79 67 55 6 91 registrants in sample
Looking at the distribution of responses across the region, there is slight under-representation in the CA area, and over-representation in the TS area, perhaps reflecting those areas location on the boundary of the region. Figures for the most populous groups are given below.
56 North East and North Cumbria Dental Workforce Survey, 2016
Dentists Nurses Therapists Hygienists Dental tech Postcode Reg Sample Reg Sample Reg Sample Reg Sample Reg Sample CA 164 67 320 96 13 6 40 23 41 0 DH 115 58 249 82 9 5 24 10 13 0 DL 160 85 327 105 12 12 27 21 19 2 NE 756 333 1041 395 55 43 111 54 128 4 SR 104 62 239 94 12 6 25 12 24 0 TS 268 178 575 285 22 25 47 32 51 12 Total 1567 783 2751 1057 274 152 276 18
Demographics
Demographic data were obtained for England as a whole rather than at the level of the region.
There are slightly more male dentists in our sample than nationally (58% compared to 53% across England).
Proportions of sexes in other professions are mostly similar, except for cases where sample numbers make analysis unreliable. For Dental Technicians, 23% rather than 5% are female nationally, 3% of orthodontic therapists nationally are male, whereas none were identified in our sample, and conversely 9% of clinical dental technicians are female nationally.
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