A shortage of NHS dentists in England and Wales
The overall NHS dentists per 1,000 population figures for England (0.374) and Wales (0.359) are low compared to many other countries (see "Background" section above). Though there is no Government target for the number of NHS dentists per 1,000 population [25], it seems appropriate to consider a figure of '0.5 dentist per 1,000 population' as an acceptable/adequate target (floor not ceiling target) based on corresponding figures for other developed countries. (The 'traffic light' map in Figure 3 adopts this figure of 0.5 dentist per 1,000 people for the lower end of its green class (>=0.5).)
We created two sets of 'traffic light' maps for England (PCTs) and Wales (LHBs), varying the thresholding of hues in each set to produce two maps, with three and four classes, for each country (Figures 3, 4, 5, 6). A general shortage of NHS dentists can be observed at a glance across England and Wales, even in the second set of maps (the maps with four classes – Figures 4, 6), which use a more "tolerant" classification with a reduced minimum of 0.4 dentist per 1,000 population for the green class (instead of 0.5), and a reduced maximum for the red band (0.2 dentist per 1,000 people instead of 0.4), with an extra orange-yellow class.
The distribution of dentists in England and Wales is not uniform, with some PCTs/LHBs suffering more shortage of dentists than others (Tables 1, 2). Dentists tend to be somewhat concentrated in major cities/urban centres and away from some of the deprived or less populated urban and rural communities, e.g., the rural South Cambridgeshire PCT with a Census 2001 population of 130,689 and only 0.16 dentist per 1,000 people as at 31 December 2002.
Although we are using 2002 dentists data for England, our results seem to echo and confirm recent media reports of a serious shortage of NHS dentists in parts of England. Whilst the mean yearly increase in NHS dentist numbers between March 1992 and March 2003 was 1.5% (with much higher percents in some years, e.g., a 4% increase in March 1998 compared to March 1997), the total number of NHS dentists in England and Wales has grown very little since December 2002 (19,379 to 19,555 as of September 2003 or a 0.9% increase), so the picture for England should be largely the same today [26]. As mentioned before, our results also reveal a shortage of NHS dentists in large parts of Wales (using 2004 data for Wales).
An important point to note is that a dentist holding a GDS (General Dental Service) contract to provide NHS services has no commitment at the present time to provide specific levels of service, and may, in fact, provide extremely limited access to NHS care and only have a small number of NHS patients.
Westminster, a very affluent area, has 0.88 dentists per 1000 population (Table 1), and as such would appear well served with NHS dentists, however, it may be that these dentists commit very limited time to NHS work and access problems to NHS dentistry may actually be quite considerable for this area.
On the other hand, Ellesmere Port and Neston, which appears to be poorly served with only 0.159 dentists per 1000 people (Table 1), may be enjoying greater access to NHS dental care, as the dentists in this area are likely to be spending most of their clinical time providing NHS treatment (see also http://www.dpb.nhs.uk/mod_dentistry/documents/December_report.pdf).
Consequently, the current figures and maps should be only taken as an indication of the level of overall provision of NHS dental services. A more complete representation of the actual access to NHS dental care in different PCTs would require more data to indicate the level of NHS provision attributed to each dentist (see "What else can be done?" below).
'Traffic light' maps for PCT/LHB performance monitoring over time
A simple time series analysis (comparing 'traffic light' maps of England and Wales for successive periods of time) can demonstrate changes over time in different PCTs/LHBs (deteriorating, stable or improving situations). If corrective programmes/interventions are implemented, we can gauge their success by watching/monitoring their effects on the targeted areas over time (e.g., a positive change from orange-yellow to green). We can then modify our plans/programmes accordingly, if needed. Animated time series maps can be also created to communicate findings (for some examples of animated time series maps, see http://circ.rupri.org/animation/).
'Traffic light' maps for PCT/LHB comparisons
We think PCT and LHB directors will be keen to look at local/regional comparisons between 'competing' PCTs and LHBs. The Georgia Medical Care Foundation Diabetes Quality Indicators project http://www.gmcf.org/Professional/initiatives/Diabetes/interactive/ provides a good example of how such comparisons could help improving practice. At a glance visual PCT/LHB comparisons as provided by our 'traffic light' maps would also certainly add much value to the kind of textual and tabular reports currently produced by the Commission for Health Improvement on PCT performance against targets http://www.chi.nhs.uk/Ratings/Search/SearchResults.asp?TrustType=PCT.
Online interactive 'traffic light' maps for better communication of results
We have also generated online versions of the 'traffic light' maps presented in Figures 3 and 6 (available from http://healthcybermap.org/PCT/dentists/ and http://healthcybermap.org/LHB/dentists/ – Figure 7). These particular online versions offer limited interactivity, and are only meant to give the reader some flavour of what can be done to share map results in better ways on the Internet or an intranet (using only a standard Web browser), and further empower the decision maker who is reading the map. Interactivity features vary depending on the software used to produce the online interactive version of a desktop GIS map [27], and include the ability of the online map user to query the map and display attribute information, to perform other GIS functions as necessary, and in the case of 'traffic light' maps to vary the thresholding of hues (class intervals in choropleth maps) and see the results of this instantly on the map, in addition to the basic map zooming and panning capabilities.
What else can be done?
Though the 'traffic light' maps and results presented in this study give some very useful insights into the distribution of the NHS dental workforce in England and Wales, we still need to investigate the factors and determinants causing, or associated with the observed distribution. Despite the improvements in oral health that have been reported since the early 1970s in many parts of the UK, the picture of dental health in deprived areas looks less rosy, with fewer people registered with a dentist (see also http://www.empho.org.uk/products/dentalreport2004.pdf). In some localities children's decay levels are as bad as they were 15 years ago [2]. A multivariate geographic analysis could be conducted of dentists distribution in different regions in relation to the following factors and determinants in these areas: (1) administrative area size and nature (urban, accessible rural or remote rural); (2) local population size, distribution, socio-economic characteristics and other demographics; (3) local transport networks; (4) figures of registration with NHS dentists and of service use (figures of visits to NHS dentists and breakdown of corresponding diagnoses/procedures); and (5) dental health indicators/outcomes (see the examples of oral health indicators published by the US National Institute of Dental and Craniofacial Research (NIDCR) and the CDC Division of Oral Health: http://drc.nidcr.nih.gov/indicators.htm). 'Traffic light' maps are much suited for mapping NHS dentist registrations per PCT, and also oral health indicators by PCT like the prevalence of untreated dental caries by age/selected demographics.
Besides examining the numbers of patient registrations with NHS dentists per PCT, investigating the total figures for the proportion of NHS to private work provided by dentists per PCT could also give a clearer indication of the level of NHS dental treatment within each PCT. Another possibility is to use dentists' practice profiles, which state annual workload and fees earned within the NHS, with comparisons with local and national figures. This might indicate the volumes of NHS work done within each PCT (see also http://www.dpb.nhs.uk/mod_dentistry/documents/pctguidancejan04.pdf).
It is noteworthy that in the US where Medicaid operates similarly to the NHS dental system (in some respects – see http://www.cga.state.ct.us/ps99/rpt/olr/htm/99-r-0428.htm and http://www.nashp.org/_docdisp_page.cfm?LID=448D07B6-6CBC-11D6-BD1100A0CC76FF4C), dentists voluntarily enroll as Medicaid providers in most states and by contract must do some things, but may not be required to participate at minimum levels or to see a certain number of Medicaid patients. Different metrics for measuring dentists' participation in Medicaid have been used or suggested, e.g., seeing a certain number of Medicaid patients within some time period, but so far there have been no agreement on a "best" measure [28, 29].
The same 'traffic light' map exercise can be also repeated for PCT 'median waiting time' and 'waiting list size' (figures included in Hospital Episode Statistics, which can be freely downloaded from the Department of Health Web site: http://www.dh.gov.uk/PublicationsAndStatistics/Statistics/HospitalEpisodeStatistics/fs/en) after determining what are the appropriate (national/target) figures for (1) waiting time; and (2) waiting list size (when addressing waiting list size, we need to take into consideration PCT population size). The maps would show PCTs with bad (red), not so bad (orange-yellow), and good/excellent waiting time/list size (green), and enable comparing and monitoring PCTs over time for these targets.
Recommendations
Suitable programmes are urgently needed to increase the numbers of NHS dentists across England and Wales. To ensure their success, such programmes must take into consideration the current distribution of NHS dentists per 1,000 people in different PCTs/LHBs, so that areas with the lowest figures (most in need) are given the highest priority. When targeting different areas, factors and determinants causing, or associated with the currently observed distributions should be also addressed for best results (see "What else can be done?" above).
Based on National Statistics' mid-2002 population estimates for England (49,561,800) and Wales (2,918,700) [12], if we are to increase the overall figure of NHS dentists per 1,000 population by just 0.1, we will have to provide extra 4,956 dentists for England and a further 292 dentists for Wales (or a total of 5,248 more dentists for England and Wales). Such large figures could be met on the short term by developing better programmes to attract more dentists to undertake more NHS work and by relying on suitably qualified foreign dental graduates (which is already taking place – see [30]), and on the longer term by providing further support to dental schools and increasing the number of dental graduates in the UK (the figure was 749 graduates in the year 2000 [31]).
Another possible short term remedy, where conditions and logistics permit (e.g., availability of suitable local transport networks), involves redirecting/reallocating resources (in controlled ways) from areas of surplus to neighbouring areas where a shortage has been detected. 'Traffic light' maps can help instantly spot areas where this might be feasible. For example, Cambridge City PCT with a relatively high figure of 0.65 dentist per 1,000 people is surrounded by the rural South Cambridgeshire PCT, which has a very low figure of 0.16 dentist per 1,000 people. It might be possible for dentists working for Cambridge City PCT to also take on their lists patients from the neighbouring South Cambridgeshire PCT, but it could be that Cambridge City PCT cannot provide for all of South Cambridgeshire PCT dentistry needs, as the combined dentist per 1,000 people figure for both PCTs together is 0.384. Royston, Buntingford and Bishop's Stortford PCT, another neighbouring PCT with a relatively high figure of 0.61 dentist per 1,000 people, can also potentially provide help to South Cambridgeshire PCT (Table 1 and Figure 4). The combined dentist per 1,000 people figure for the three PCTs is 0.43.
The above recommendation may in fact be already taking place, as patients are free to visit any NHS dentist in any area, and many patients choose a dentist who is more conveniently located in relation to their work rather than home. This is often why there are increased numbers of dentists in city centres where people are employed, rather than in the suburbs.
In all cases, NHS work needs to be made more attractive to dentists, e.g., by offering them better payment schemes.
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