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Background: In primary care dentistry, strategies to reconfigure the traditional boundaries of various professions by task sharing and role substitution have been encouraged in order to meet changing oral health needs. Training dental professionals as a team in order to encourage collaborative practice has been part of this agenda. The focus of the first part of this research is the study of patients and the care activities at the University of Portsmouth Dental Academy (UPDA) and its predecessor organisation. This is a primary care learning institution, where mid-level dental providers; hygiene-therapists (HTS) and dental nurses (DN), train together as a team with dental students on an outreach placement. UPDA was established in September 2010, as a joint venture between the University of Portsmouth’s School of Professionals Complementary to Dentistry (SPCD) and King’s College London Dental Institute (KCLDI), with the objective of improving team working. Aim: The aim of this research was to investigate the patient base, treatment activity and skill mix practice at a primary dental care team training centre prior to, and after, its establishment, and to model the potential for skill mix use in national primary dental care based on the undergraduate training experience in this centre. Methods: This research involved a case study and an operational research modelling exercise. The former was undertaken using cross-sectional electronic patient management data from UPDA, extracted in two phases: a pilot, which covered two years around the period of UPDA’s establishment [2009/10 and 2010/11], and the main data spanning a four-year period before and after UPDA was established [2008/09 and 2011/12]. The data were used to investigate the patient base, expressed treatment needs and skill mix practice using univariate, multivariate and multilevel regression analyses. An operational research model and five alternative scenarios to test the potential for skill mix use in primary care were developed, as informed by the model of care at UPDA, professional policy including scope of practice, and contemporary evidence based practice. The five scenarios included: ‘No skill mix’, ‘UPDA model nationwide’, ‘Direct access’, ‘More prevention’ and ‘Maximum delegation’. The scenario outputs were clinical time, workforce numbers and salary costs. Results: The pilot data findings from 4,343 patients suggest that there was a significant change in the patient base when the new services were initially instituted: the new patient base was older (on average 4.7 years older p=0.001); with more patients non-exempt from payment 56.8% (994) to 71.4% (1,853) (p=0.001) with lower deprivation scores; 24.5 (95%CI: 23.8, 25.2) cf to 22.3 (95%CI: 21.7, 22.8); however, there was an increased likelihood of attending in the post-expansion period for patients with a higher geographical barriers to services score, i.e. those further away from services were more likely to attend the new expanded service (0.7%; OR: 1.007 (95% CI: 1.002 to 1.012). From the main extract analysis 10,341 closed/completed treatment plans which were undertaken on 6,351 patients seen over the four-year study period showed an increase in the proportion of patients completing care plans who were in the age groups of 45-54 years and 55-64 years and adult non-exempt from NHS charges. Increasing age was associated with a higher volume of expressed treatment need in general. Logistic regression analysis showed statistically significant association p<0.05: between having received common treatments at least once in the four-year period. Payment exempt adult patients were more likely to receive all common treatments compared with the non-exempt: partial dentures (x2.6), tooth restorations (x2.1), instruction/advice (x2), tooth extraction (x1.8) and scale/polish (x1.7). The least deprived were 50% more likely to have scale and polish and 50% less likely to have tooth extractions than the most deprived. Smokers compared with non-smokers had a higher likelihood of receiving tooth restorations (57%), instruction/advice (x4), scale/polish (x1.7), tooth extractions (x2) and partial dentures (x2.6). Females patients were 20% less likely a tooth extraction or a restorations compared to male patients. Multilevel analysis indicated that the area of residence explained 7% of the variance in rate of instruction/advice, 3.8% in scale and polish and 2.8% of the variance in tooth extractions. From a sub-sample data of patients and treatments coded by provider of care n= 2,063, 55% of patients had been delegated to hygiene-therapy students at least once and 46% of coded treatments had been delegated. A significantly higher proportion of children were delegated compared with adults (85% cf 50%; p=0.001). Similarly adult smokers were delegated at a higher rate compared with non-smokers (p=0.01). The rate of delegation of different treatments also varied, with preventive treatments highly delegated (85-90%) and restorative work moderately delegated (60%). The operational research model suggested that the majority of clinical time in NHS primary care is spent on tasks that could be delegated to dental care professionals (DCP). While 45-54 year old patients received the most clinical time. Using estimated NHS clinical working patterns, the model suggested that NHS workforce numbers and salary costs to meet the dental demand in 2011/12 for each scenario were i] ‘no skill mix’ dentist only scenario would require only 81% of the dentists currently registered in England. Ii] The ‘UPDA nationwide’ scenario would lead to 29.5% of clinical time delegated to hygiene-therapists and a 357% increase in hygiene-therapists and only 57% of the dentists currently registered in England would be required and this would lead to a 19% salary cost saving cf. the ‘no skill mix’ model. iii] Minimal ‘direct access’ scenario where 70% of examinations were delegated and UPDA’s model of skill mix was practised would require 40% of registered dentists and eight times the number of hygiene-therapists’ registered; this would save 38% salary cost cf. ‘no skill mix’. iv] ‘More prevention’ i.e. increasing fluoride varnish from 13.1% to 50% and maintaining UPDAs model of skill mix, would require 4.7 times the number of hygiene-therapists’ and 57% of registered dentists. It would be a 1% salary cost saving cf. ‘no skill mix’. v] ‘Maximum delegation’ scenario with all care within hygiene-therapists’ jurisdiction delegated at 100% except restorations and radiographs (50%), showed that only 30% of registered dentists would be required and ten times the number of hygiene-therapists’ registered. This scenario could have a 52% salary cost saving cf. a ‘no skill mix’ scenario. Conclusion: The patient base in this primary care training facility represented a wide range of the societal spectrum as would be expected in general primary care practice. There was a significant change in patient base following introduction of new services and team training, to an older, more non-exempt and more geographically deprived patient population. The trend in care was associated with socio-demography and indicated increasing expressed treatment need from middle-aged patients, males and adults who would have normally had to pay for care. Over the four-year study period, routine treatments such as instruction/advice and tooth restorations, which can be undertaken by hygiene therapists, were common and patients were more likely to receive them with increasing adult age, smoking and being an adult exempt from payment. More advanced care such as tooth extraction was more common for the most deprived and smokers when compared with their counterparts. Children and adult smokers were more commonly delegated to hygiene-therapy students. Alternative scenarios based on wider predictors of expressed treatment need, changing regulations on the scope of practice and increased evidence-based practice, suggests that majority of care in primary dental practice can be delegated to hygiene-therapists and there is potential time and salary cost saving if the majority diagnostic tasks and prevention were delegated. However, this would require either more training or enhancing of roles of mid-level dental providers.

Person-centred care (PCC) is recognised as one of the key domains in measuring quality within health care, with patient feedback playing an increasingly important role in assessing the level of service delivered. This has been developed within the general medical services in the UK through the Quality Outcomes Framework and a similar model within general dental practice is currently being piloted. Measurement of PCC as an indicator of quality is likely to be highly relevant within the new Dental Quality Outcomes Framework (DQOF) and the Care Quality Commission key lines of enquiry toolkit. It is important that we are able to understand what we aim to measure before we can consider implementing a tool with which to measure it. This research project aims to understand what is meant by the term "person-centred care” in relation to general dental practice, with the intention that the findings may subsequently be used to inform development of a suitable tool to accurately measure PCC in the future. The research strategy was based on a systematic review and the use of qualitative methods to explore the views of patients and dentists towards PCC in dentistry. The systematic review identified a limited body of research associated with PCC in dentistry, with no studies involving the views of patients. This limited information was used in conjunction with the findings from my qualitative research to identify the key features which are relevant to the delivery of PCC in general dental practice. These features were categorised as relational and functional aspects of care. Relational aspects of care were considered to be closely aligned to the provision of PCC and viewed as an integral feature of its successful delivery. Four dimensions of relational aspects of care were identified: • Connection • Caring attitude • Communication • Control Two sub-categories of functional aspects of care were identified as physical environment and healthcare system, and these were considered to be influencing factors in the delivery of PCC. A provisional model of PCC was developed based on fhe research findings from the patient interviews and introduced during the dentist interviews. It is suggested that future research should include testing of this model to allow refinement and validation.

Aim: To investigate which characteristics of primary care organisations influence the translation of guidance into practice. Methods: A three phase multi-method design. (1) A literature review exploring organisational change in primary healthcare organisations, focusing on knowledge translation; (2) Development of a dental team questionnaire measuring structure, culture and management; (3) A dental team questionnaire and case studies, to collect data on the structure, culture and management of dental practices along with self-report compliance data exploring the relationship between organisational characteristics and guidance compliance. Key Results: A ‘best-fit’ framework approach was undertaken for the literature review. This identified the barriers and facilitators to the translation of guidance in primary care organisations. These were communication, team work, flexibility, prioritisation, collaboration, dissemination and expectations. Preliminary interviews with dental team members supported these findings and identified further practice characteristics to explore in the questionnaire. These additional themes were leadership, context and practice systems and learning. A dental team questionnaire, incorporating the Dental Practice Organisational Measure (DPOM), along with questions to determine practice characteristics and compliance with key dental recommendations was developed, piloted and then disseminated to 400 dental practices. Questionnaire findings revealed no significant relationship between practice characteristics and compliance with Emergency Dental Care (EDC) or Drug Prescribing recommendations. However positive associations were observed between compliance with Oral Health Assessment and Review (OHAR) recommendations and having a Practice Manager as well as with whether a practice is fully NHS, fully private or offers a mixture of treatments. These findings were supported by case study data that identified leadership and context as key drivers in the translation of guidance. Regression models to explore the relationship between the variables in the DPOM tool compliance with EDC and OHAR recommendations also revealed some associations. Conclusions: A multi-method approach, set within the context of General Dental Practice, was undertaken to explore which characteristics of primary healthcare organisations influence the translation of guidance. Integration of the findings suggest the emergence of two conceptual themes around the relationships and the structural and administrative aspects that exist within healthcare organisations. It may be that new guidance and recommendations should be tailored to incorporate these factors in order to facilitate knowledge translation and hence improve compliance with best practice recommendations.

Much of the workload of primary dental care teams in remote-rural Scotland consists of treating periodontal disease, an inflammatory condition for which smoking is a proven risk factor. This thesis sought to ascertain the effectiveness of a smoking cessation intervention applied in a primary care dental setting and employed a narrative literature review to explore periodontal disease, smoking and smoking cessation interventions. This literature review informed the design of a randomised controlled trial which failed due to lack of recruitment. The Medical Research Council Framework for the Development and Evaluation of Complex Interventions was employed to provide structure to the modelling of a feasibility trial likely to succeed in evaluating the benefit of smoking cessation provision in rural dental settings. A systematic literature review was undertaken to evaluate evidence regarding prevalence of periodontal disease, tobacco use and the effectiveness of tobacco cessation interventions applied in remote-rural areas. This identified a dearth of robust evidence particularly in relation to smoked tobacco. In order to model a feasibility study better adapted to the current study population, a prevalence study exploring the smoking attitudes and behaviours, the oral health-related quality of life and periodontal status of 398 dental patients was undertaken at the two study locations. Twenty three percent of the participants were found to be smokers and periodontal health was significantly poorer in those who smoked. Both smokers and non-smokers strongly agreed that dentists should be involved in provision of smoking cessation activities. The willingness of smokers to quit was not related to the degree of periodontal disease they experienced, suggesting that periodontal health is not valued sufficiently to factor into a decision to stop smoking. However periodontal health and smoking status both impacted greatly on oral health-related quality of life. It is recommended that a feasibility trial be undertaken in remote-rural primary dental care of a smoking cessation intervention which forms an integral part of periodontal care and focuses on improving quality of life parameters rather than periodontal measures.

Background. Most dental planners use the normative approach for dental workforce planning. An alternative, the sociodental approach of need assessments has been developed to assess dental needs. Studies indicate large differences in needs assessed using the two methods.;Objectives. To assess and compare dental needs and manpower required for dental care of a sample of adult Koreans aged 30 to 64 years using the normative and the sociodental need approaches for three dental treatments restorative, prosthetic and periodontal treatments.;Methods. Assessments of dental needs and time required to treat using two approaches were based on analysis of data obtained from a sub-sample of 1029 30-64 year-old-adults from the 2003 Korean National Oral Health Survey. They were clinically examined for normative needs and interviewed using an Oral Health Related Quality of Life (OHRQoL) measure and their oral health related behaviours to assess propensity. Two needs methods were generated: 1. Normative Need (NN) defined by dental professionals 2. Socio-Dental Approach (SDA) that includes Impact-Related Needs (IRN) using an OHRQoL measure, OIDP, and Propensity-Related Needs (PRN). Amount of dental needs, time to treat, and numbers of dentists needed per 100,000 people were estimated for restorative, prosthetic, and periodontal treatments using NN, IRN and PRN.;Results. Significant differences of about 72% existed between estimates of need for prosthetic treatment using NN and IRN. In workforce estimates, the differences in dentists required to treat 100,000 people were 87.1 dentists would be needed using NN compared to 22.8 dentists for IRN and 18.9 for PRN for prosthetic treatment 22.5 dentists using NN compared to 15.9 or 2.7 using PRN for periodontal treatment and 8.8 dentists using NN compared to 6.6 for PRN for restorative treatment.;Conclusions. The socio-dental approach for assessing dental needs found lower levels of treatment need than the normative approach. The socio-dental approach should be applied to dental workforce planning.

The Shirley Glasstone Hughes Trust Fund (SGHTF) instigated a research agenda-setting process to ensure its primary research commissioning was targeted at the topics of most relevance to primary dental care practitioners. Overall, the objective was to reduce barriers to evidence-based dentistry practice. A web-based system generated research topic nominations, and a resource- constrained rapid evidence review process produced Evidence Summaries for use by practitioners and research commissioners, launched in May 2009. Nine Evidence Summaries were published in the British Dental Journal, and SGHTF used these outputs to inform research commissioning. This health services mixed methods research aimed to evaluate the implementation of the SGHTF research agenda-setting process. Feasibility and effectiveness of setting up and running the web-based system, and implementation of the newly-designed rapid review process was assessed using a range of component studies: semi-structured interviews with research commissioners; quantitative and qualitative assessment of the reviewer's activity diaries; quantitative assessment of dental practitioners' research topic nominations and voting (online topic prioritisation); postal surveys (as part of the British Dental Association's national Omnibus Surveys) to dentists, and an e- survey to research commissioners to assess usefulness and relevance of research topics generated and rapid reviews completed. The findings showed that both the web-based system and the rapid review process were feasible. However, levels of engagement with the former by dentists were modest, due to the implementation approach. Evidence Summaries were found to be of relevance and useful to practitioners and research commissioners. Similar organisations seeking to enhance evidence-based practice are encouraged to draw upon relevant expertise at an early stage in planning new initiatives. Full appreciation of what communication is possible through online means, how it fits into their mission overall, and what is involved, is required at the outset to achieve successful on line stakeholder relationship building.

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Using a case study approach this research explored the research question 'How did the powering and participation of a group of actors tasked with implementing a School for Dental Care Professionals influence implementation?' The School, an important case, changed the nature of Dental Care Professional education in the United Kingdom being the first of its kind to be based on a University campus, remote from a traditional dental school and in the primary care dental setting. Partnership characterises the nature of modern day health and education policy-making in the United Kingdom and the implementation of the School, a complex multi-agency project between a University, a National Health Service education commissioning body, the local dental profession and the Department of Health, was no exception to this. Ten actors tasked with implementing this policy episode took part in the study. A body of knowledge associated with policy implementation, powering and participation (specifically group development theory) underpinned the conceptual framework informing this research. Data were captured via participant observation and semi-structured, one-to-one interview. Data were analysed using a long table qualitative approach. Vignettes or extended quotes are given as meaningful support in terms of making explicit the conceptual grounds that informed the interpretation of this case. The findings of this research offer three original contributions to the body of policy implementation literature. The first is that powering and participation are inter-dependent in the puzzling of policy implementation; previously a theoretical assumption alluded to in the literature. The second is that the processes of group development do not necessarily follow the theoretical hypotheses of development previously described within the literature. The third is that complex multi-agency implementation partnerships can successfully implement policy outcomes under certain conditions. The thesis argues the need for further research which recognises the inter-dependence of powering and participation on implementation. Key words: policy implementation, dental care professional education, powering and participation.

This thesis seeks to understand why NHS dentistry is yet to effectively respond to the changing demographic and epidemiological distribution of dental disease in the UK. The analysis suggests that the current stasis in NHS dentistry requires a broader explanation that situates the dental service within the wider political economy of healthcare reform. Drawing from Michel Foucault’s concept of biopolitics and a reformed critique of neoliberalism, it is argued that market logic, individualism and consumerism are holding NHS dentistry in a transformational stasis. As both a scientific discipline and a professional occupation, it is argued throughout that understanding the slow pace of reform in NHS dentistry requires a deeper understanding of how science and practise are shaped by neoliberal prerogatives. An extended critique of state-of-the-art dental science and an extensive qualitative study show that the further extension of the market has been accompanied by an obsessive political drive to quantify science and practise, disallowing a wider debate about the direction of the service. The NHS dental service hangs in a precarious balance as professionals try and manage competing objectives and align or converge with policy discourse. As such the political future of NHS dentistry is understood as the reflection of how professionals re-imagine and enact their roles under the restraints of contemporary political economy, and a new opening for a social scientific understanding of dental reform is outlined. The ultimate synthesis of the work suggests that reform of NHS dentistry must recognise, and work within, these constraints if progress is to be made. Closing with a discussion of a possible way forward, the final chapters seek to move beyond critique to outline how policy can effectively integrate dental policy reform within political economic constraints.