This article will explore the evolution of the dental team in relation to our society's oral health requirements viewed through political, financial and social lenses

Previous authors of Dental Nursing (Marshall, 2014; Singh, 2014) have discussed the opportunities that exist for dental nurses within the dental team and how these opportunities can contribute to the delivery of patient care. These opportunities have occurred as a result of a number of political, financial and social positions that have, perhaps, influenced and shaped the direction of travel when considering the evolution of the dental workforce.

History of the NHS and politics

Since its formation in 1948, the NHS has developed and evolved into a complicated range of health and social care services (Glasby, 2012). The NHS is currently experiencing the most significant restructure in its history, which directly affects dental care services. The introduction of the Health and Social Care Act 2012 abolished primary care trusts (PCTs) and transferred the commissioning of services to NHS England (General Dental Council (GDC), 2013a; NHS, 2013; Gorsky et al, 2014).

Health services have been provided with varying degrees of public satisfaction (Appleby, 2011; The Kings Fund, 2014). As ill health touches society almost without discrimination and creates a continuing demand for NHS services, it is not surprising that we witness government interventions.

The financial crash of 2008 and world recession triggered a restructure, reorganisation, and reduction in health service provisions by the then-Labour government and the current coalition government, which has affected society's ability to access NHS services (Baggott and Jones, 2014). Considering that society perceives the NHS as a valued institution (Tickle, 2012), the reduced access to services may provide the answer for the increase in recent public dissatisfaction with the NHS (Ipsos Mori Social Research Institute, 2012).

Oral health care services and the state financial envelope

Since the recent downturn in the UK economy (Ham, 2009; Cleaver, 2013), it is no surprise that oral health budgets have been under scrutiny (Ham, 2009; Brocklehurst and Tickle, 2011; Glasby, 2012). A number of reports have been commissioned by governments in recent years that propose streamlining services (House of Commons Health Committee, 2008). Even though new technology has contributed to escalating NHS costs (Baggott and Jones, 2014), it has also served to provide remote consultations and diagnosis for patients in an attempt to solve access and cost issues (NHS, 2002; GDC, 2013a; Patel and Antonarakis, 2013).

NHS dental services are funded by the state and provided by NHS dentists through an NHS contract. Historically, the contract recompenses the disease with less emphasis on prevention (Brocklehurst and Tickle, 2011; NHS, 2009a; Whittaker and Birch, 2012). It has been observed over time that these contracts have influenced working practices due to the structure and process of remuneration (Chalkley and Tilley, 2006; Bullock and Firmstone, 2011; Brocklehurst et al, 2013; Northcott et al, 2013).

The NHS Dental Services in England. An independent review led by Professor Jimmy Steele (also known as the Steele Report) recommended future use of a wider workforce that included DCPs (NHS, 2009a). Four years later, the Centre for Workforce Intelligence (CfWI) forecast an oversupply of dental graduates, which would not be sustainable in this economic climate (CfWI, 2013). This has become a further influence towards expanding the dental team (Tickle, 2012).

Figure 1.Dental staff's skill mix will be expanded to provide a major role in future oral health care

Oral health care and the socio-economic landscape

Today's dental requirements are very different to those of past decades, mainly attributed to the introduction of fluoride toothpaste and water fluoridation (Kent and Croucher, 2002; Levine and Stillman-Lowe, 2009; NHS, 2009a; Brocklehurst and Tickle, 2011; Richards et al, 2014). As a result, our oral health has greatly improved, with current generations experiencing less caries (Brocklehurst and Tickle, 2011; Gallagher et al, 2013).

The Steele Report stated that ‘the NHS in 2009 is still dealing with, and paying for, the consequences of disease that developed more than fifty years ago’. It goes on to report that ‘good oral health’ should be our primary focus, indicating a need for prevention incentives in a new NHS dental contract (NHS, 2009a).

As a result, the new proposed NHS dental contract is being piloted in England to establish new contractual payments for dentists (Department of Health (DH), 2014a). The new contract has been at the centre of continued discussion and debate by all areas of the profession (House of Commons Health Committee, 2008; NHS, 2009a; CfWI, 2013; GDC, 2013a; DH, 2014a; Lewney, 2014).

Prevention is better than cure (Baggott and Jones, 2011), and indeed we perceive this as a guiding principle in health (Kent and Croucher, 2002). To uphold this principle, society has been subjected to a number of recent government public health campaigns in an attempt to help reduce the cost of treating chronic diseases (Chapple and Wilson, 2014; DH, 2014b). It can be argued that society itself should take responsibility to improve its general health to avoid the financial strain on the NHS purse. However, The Marmot Review (2010) and the Royal College of Nursing (2012) indicated there are social determinants to health outcomes that may contribute to barriers in influencing individual wellbeing.

Relating this to oral health, a number of chronic diseases have a negative effect on oral health, and DCPs could be involved in screening and early education. In their recent study, Creanor et al (2014) researched the attitudes towards screening for diabetes in a dental care setting and concluded that the majority of respondents were willing to be screened by a member of the dental team. It is possible, therefore, that the wider dental workforce could be trained to screen for chronic diseases, in a dental setting, in an attempt to reduce the financial burden placed upon the NHS (Chapple and Wilson, 2014).

In addition, some of the middle-aged population have lifestyle habits of smoking and alcohol consumption (Baggott and Jones, 2014), which has created a shift in poor oral disease patterns and an increase in the prevalence of oral cancer (Cancer Research UK, 2014). A strong relationship between smoking and high alcohol consumption with oral cancer has been reported in the literature (Hill et al, 2013; Cancer Research UK, 2014; Chapple and Wilson, 2014), providing further scope for DCPs to screen patients in a dental care setting (Gallagher and Wilson, 2009; Northcott et al, 2013).

When looking towards the oral health requirements of our society in 2020, a compelling fact is that the population is living longer. Not only does this impact financially upon the NHS (Tickle, 2012), but raises the question of who will be providing future oral health care for this older section of society (Gallagher et al, 2010) living with illnesses attributed to later life (GDC 2013a). Gallagher et al (2010) raised an important question: ‘How can dental professionals meet the needs and demands for older people in England?’ Are there benefits to widening the workforce to provide future oral health care for the elderly?

A changing workforce

Looking back seven years, is it fair to say the combination of mandatory registration and direct access have provided the impetus to develop the dental team (NHS, 2009a; GDC, 2006; CfWI, 2013; GDC, 2013b; GDC, 2013c). The same year that the Steele Report was published (NHS, 2009a), Gallagher and Wilson (2009) concluded that, as a profession, dentistry needed to ensure that it was patient-centred and promoted oral health—the idea of team-working was deliberated as a feature of future oral healthcare.

The scope of practice in the wider dental team, known as DCPs, has not remained static since the introduction of DCP registration (GDC, 2006; CfWI, 2013; GDC, 2013b). The Office of Fair Trading (2012) recommended the removal of the limitation of trade for dentists to enable patients' greater access to dental care services through other members of the dental team: DCPs. As a result, the GDC announced direct access to patients (GDC, 2013c), which has defined new expanded duties for DCPs that were once carried out by dentists (GDC, 2013b).

Corporate dentistry cannot be ignored when considering the evolution of the dental team (Newsome, 2002; Bullock and Firmstone, 2011; GDC, 2013a; Holden, 2013). Holden (2013) reports that in 2011, corporate dentistry supplied 11.3% of NHS dental services. Furthermore, Watson (2012) and Chestnutt et al (2009) noted that the 2006 dental contract allowed corporate bodies to expand further as many NHS dentists moved away from NHS dentistry. Whittaker and Birch (2012) continued by commenting that corporate models encourage part-time working, thereby introducing another component to the evolving dental team.

Opinion has been divided between dentists and DCPs on the introduction of direct access for patients, with some resistance to change (Bullock and Firmstone, 2011). Conversely, Meese (2013) commented that direct access to patients was a ‘fantastic decision’ made by the GDC ‘for both DCPs and patients alike’.

Brocklehurst and Tickle (2011) highlighted the concept of using extended duties dental nurses (EDDNs) in general practice, when considering the DH's guidance on application of fluoride varnish (NHS, 2009b). However, the paper concludes that the 2006 dental contract places pressure on referral and appointment structures within general practice, and may act as a disincentive to use EDDNs.

More recently, Macleavey (2013) questions whether dental nurses are ‘fulfilled and appreciated’ in relation to their careers and extended duties. The analysis of her survey concluded that 65% of the sample felt fulfilled in their role; however, fewer ‘felt appreciated’ (56%) and of those who wanted to ‘do more’ (37%) it was likely they would have to fund the additional training themselves.

The combination of these findings provides some further support for the debate in not only widening the workforce to provide a major role in future oral health care, but how that concept will be co-ordinated and funded.

Funding the new workforce

In recent years, there has been an increasing amount of literature on NHS dental contracts influencing the way dentists work (Chalkley and Tilley, 2006; NHS, 2009a; Brocklehurst and Tickle, 2011; Brocklehurst et al, 2013; GDC, 2013a). It could be argued, therefore, that in an attempt to influence the use of the wider DCP workforce, logic dictates any new contract would endorse this observation (Bullock and Firmstone, 2011). Brocklehurst and Tickle (2011) called for more appropriate financial incentives for the use of skill mix in the redesign of the dental contract. The Steele Report (NHS, 2009a) stated that commissioners needed to recognise the use of a wider dental workforce to facilitate the delivery of a cost-effective service. However, the new contract failed to reveal how the wider dental workforce would be remunerated where the use of extended duties are involved. Hence, it could be hypothesised that some DCPS would fail to engage in extended duties where no incentives existed. Interestingly, the second report on the dental contracts' pilot evidence (DH, 2014a) stated that training for EDDNs was quick and inexpensive. However, there was no evidence in the report to support this statement, suggesting it is possible that an undercurrent of policy decision has already been made, influenced by non-DCP dental colleagues (NHS 2009a; DH, 2014a; GDC, 2012; GDC, 2013a).

The future workforce

The current dental landscape reflects the increased potential of implementing skill mix within the dental team (GDC, 2013b). Evidence advocating the use of the wider dental team is overwhelming (Nuffield Foundation, 1993; Gallagher and Wilson, 2009; NHS, 2009a; Rowbotham et al, 2009; Gallagher et al, 2010; Brocklehurst and Tickle, 2011; Turner et al, 2011; GDC, 2012; CfWI, 2013; Dyer et al, 2013; Gallagher et al, 2013; Northcott et al, 2013), which can be argued has arisen from the need to address the financial health of the state, as well as to satisfy an ageing society's intrinsic requirement to be treated by the state. The debate for using a dentist (an expensive commodity) to treat disease, when prevention should be rewarded (Brocklehurst and Tickle, 2011), is reflected in the the Steele Report, further supporting the use of skill mix and DCPs (NHS, 2009a).

One criticism of much of the literature on skill mix and widening the dental workforce is that the majority of the authors have been dentists. Gallagher et al (2013) and Robinson et al (2012) discuss benefits to patients in terms of greater access to care by utilising the skill mix of the UK dental workforce for a range of population groups. In addition, Northcott et al (2013) draw our attention to models of successful integrated direct access practice in the Netherlands, with a particular focus on DTs. To demonstrate this further, Bullock and Firmstone (2011) question the ability of the collective force among policy makers and the dental profession to make a real change to the role of the dental team in developing the skill mix in UK primary care dentistry.

One question that needs to be asked, therefore, is whether the wider workforce wants to be developed in this way (DH, 2014a). There was very little evidence of research conducted by DCPs on the question of skill mix and extended duties. It could be argued that external forces such as politics, economics, social determinants, and technology may in fact be the drivers of change to meet oral health requirements in 2020 (GDC, 2013a).



It can be concluded that significant change has affected NHS dentistry and its workforce in recent times; and, as a result of the world recession, the cost of provision has been under the spotlight (Batchelor, 2012; Gallagher et al, 2013).

Furthermore, it can be acknowledged that previously the dental team was led by the dentist (GDC, 2013a; Innes and Evans, 2013). Since 2008, however, DCP registration and direct access have provided the impetus to develop the dental team, changing the practical scope of dentistry.

A pivotal element of the continued evolution of the dental workforce into 2020 is the new dental contract (DH, 2014a). Resistance to change exists (Bullock and Firmstone, 2011; Tickle, 2012; Innes and Evans, 2013; Lewney, 2014); however, market forces and policy makers continue to influence the new dental contract (NHS, 2009a; Bullock and Firmstone, 2011; DH, 2014a). Professionalism and power cannot be ignored when observing the changing dental landscape. However, perhaps this is why there is very little evidence on DCP opinion on extended duties, direct access, and the new dental contract that proposes a prevention led, patient-centred approach to oral health care provision (NHS, 2009a).

While it is fair to say not all DCPs would be interested in extending their skills (Macleavey, 2013), questions remain: for those who do, who will be funding the development of these new roles and will the NHS be prepared to pay for their service?