Access And Barriers To Care Flashcards
Why don’t people go to the dentist?
- Apprehension
- Cost
- Perception of need differs
- Can’t find a dentist
- Journey time
- Taking time off work
- Receptionist attitude and atmosphere in waiting room
- Smell, noise, taste etc
- Feeling vulnerable
- Relinquishing control
- Dentists associated with discomfort
- Impersonal ‘see you as a mouth’
- Personality of dentist
What is access?
The general concept describing the fit between the patient and the healthcare system. It can be measured in terms of:
- availability-inverse care law
- accessibility-transport and spatial
- acceptability-expectations
- affordability-direct and indirect costs
- accommodation-opening hours etc
What are the reasons for attendance?
- As a preventative measure
- Out of habit
- Example to children
- Awareness of gum problems (lots of adverts)
- In response to promotion of prevention
What is the inverse care law?
The availability of good medical care tends to vary inversely with the need for it in the population served.
In dentistry may not fully apply as government puts outreach places in areas most needed etc. but there are fewer dental practises (esp private) in deprived areas and these communities have more unmet treatment need.
What are the barriers to social care?
- physical (distance to practice, public transport, wheelchair access, stairs)
- social (cost, perception of need)
- psychological (fear, apprehension, smells etc)
What’s age related presentation?
- childhood (past dental experiences)
- childhood (present very different they love the dentist)
- leaving school (pattern likely to be broken, apathy, inertia, transition)
- resuming attendance (parenthood, problems, fear of problems)
How can we remove barriers?
- reduce level of charges
- clearer charging system
- estimate of costs before treatment
- image/approach of dentist (caring, personal touch, reduce waiting times)
- extend hours of opening
- location of surgeries
- open surgeries
What is the legislation regarding access to care? The disability discrimination act (DDA) and later the equality act have addressed this and put in rules that we must follow.
- applicable to dentists from October 2004
- you must enable access to all patients regardless of disability:
1. Sensory-clear markings, hearing loops etc
2. Physical- ramps, stair lifts, width of corridors etc
How are services commissioned?
There used to be a registration system and you were registered for a period of time but then you could be discharged from books (and dentist would no longer be obligated to treat them).
There’s been a greater shift to private care (which public perceive as not affordable).
The patterns of working have changed, no longer a set recall of 6 months it’s dependent on the patient. Also there’s now a great skill-mix, dentists aren’t the only ones doing all the dentistry, good way of managing costs.
What professional determinants affect access to care?
- reduced training numbers in 1980s
- more females and they have been proven to take more career breaks and tens to work shorter hours
- early retirement more common
- changing expectations of the public
- locations chosen by dentists (they choose the nice areas where there’s perhaps less need for them)
What happened at the end of the old contract and what’s happening now?
Steady fall of people accessing dental care but as the situation wasn’t static (15 month registration period) the people accessing care was always turning over. Used to be that more than 80% of dentists income was from the nhs much less than that now. There was a real problem for accessing urgent dental care.
What are the options for chance in nhs dentistry?
- tackling inequalities
- PCT commissioning: devolved budget, focus on needs
- remuneration: (quality not quantity, removed perverse incentives)
- delivery: (evidence based, wider skill mix
- patient charges: simpler
- workforce: training pathways
How was the new contract developed?
- PDS scheme:tested variety of models
- DAC’s: urgent access centres
- targets times/distance to urgent care
- no registrations
- open access encouraged
But this caused a 10% fall in dental activity and recall intervals were increased (supported by NICE guidelines) but this drove more dentists out of the nhs.
Quick summary of the new contract (2006) which has been better for patients but caused more dentists to go private
- more time for procedures, asked to provide a certain number of units of dental activity and that’s what you’d be paid for even if you did more
- simpler charging system (3 +1 bands)
- income separated from treatment
- encouragement to use DCPs (dental care professionals eg dental therapists)
- focus on prevention
- focus on quality (treatment driven by evidence based)
- recall interval increased (NICE guidelines)
What happened one year on?
Access been very difficult to nhs dentist. 1 million fewer patients have been able to see nhs dentists and there’ve been changes to the type of treatment they’re receiving: less RCT’s and less treatment involving lab work as they’re less cost effective. Therefore review recommended. BUT then in 2011 there was suddenly an increase in patients being seen by the nhs but may only have been one time they were being seen, not sure if there were receiving full oral care or just emergency care. Government so worried that they’ve now increased number of training places and dental schools, more training in primary care settings (outreach), emphasis on communication skills, emphasis on public health approach, more DCPs trained and more team working.
