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Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study.


Southampton (UK): NIHR Journals Library; 2016 Jul.
Health Services and Delivery Research.

Author information

School of Healthcare Sciences, Bangor University, Bangor, UK
Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
Manchester Business School, University of Manchester, Manchester, UK
School of Dentistry, University of Manchester, Manchester, UK



Maximising health gain for a given level and mix of resources is an ethical imperative for health-service planners. Approximately half of all patients who attend a regular NHS dental check-up do not require any further treatment, whereas many in the population do not regularly attend. Thus, the most expensive resource (the dentist) is seeing healthy patients at a time when many of those with disease do not access care. Role substitution in NHS dentistry, where other members of the dental team undertake the clinical tasks previously provided by dentists, has the potential to increase efficiency and the capacity to care and lower costs. However, no studies have empirically investigated the efficiency of NHS dental provision that makes use of role substitution.


This programme of research sought to address three research questions: (1) what is the efficiency of NHS dental teams that make use of role substitution?; (2) what are the barriers to, and facilitators of, role substitution in NHS dental practices?; and (3) how do incentives in the remuneration systems influence the organisation of these inputs and production of outputs in the NHS?


Data envelopment analysis was used to develop a productive efficiency frontier for participating NHS practices, which were then compared on a relative basis, after controlling for patient and practice characteristics. External validity was tested using stochastic frontier modelling, while semistructured interviews explored the views of participating dental teams and their patients to role substitution.


NHS ‘high-street’ general dental practices.


121 practices across the north of England.


No active interventions were undertaken.


Relative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients.


The utilisation of non-dentist roles in NHS practices was relatively low, the most common role type being the dental hygienist. Increasing the number of non-dentist team members reduced efficiency. However, it was not possible to determine the relative efficiency of individual team members, as the NHS contracts only with dentists. Financial incentives in the NHS dental contract and the views of practice principals (i.e. senior staff members) were equally important. Bespoke payment and referral systems were required to make role substitution economically viable. Many non-dentist team members were not being used to their full scope of practice and constraints on their ability to prescribe reduced efficiency further. Many non-dentist team members experienced a precarious existence, commonly being employed at multiple practices. Patients had a low level of awareness of the different non-dentist roles in a dental team. Many exhibited an inherent trust in the professional ‘system’, but prior experience of role substitution was important for social acceptability.


Better alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical.


Output data collected did not reflect the quality of care provided by the dental team and the input data were self-reported.


Further work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision.


The National Institute for Health Research Health Services and Delivery Research programme.

Copyright © Queen’s Printer and Controller of HMSO 2016. This work was produced by Brocklehurst et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

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