1 Robinson PG, et al. BMJ Open 2019;9:e031886. doi:10.1136/bmjopen-2019-031886 Open access Remuneration of primary dental care in England: a qualitative framework analysis of perspectives of a new service delivery model incorporating incentives for improved access, quality and health outcomes Peter G Robinson, 1 Gail V A Douglas, 2 Barry J Gibson, 3 Jenny Godson, 2,4 Karen Vinall-Collier, 2 Sue Pavitt, 2 Claire Hulme 5 To cite: Robinson PG, Douglas GVA, Gibson BJ, et al. Remuneration of primary dental care in England: a qualitative framework analysis of perspectives of a new service delivery model incorporating incentives for improved access, quality and health outcomes. BMJ Open 2019;9:e031886. doi:10.1136/ bmjopen-2019-031886 ► Prepublication history for this paper is available online. To view these fles, please visit the journal online (http://dx.doi. org/10.1136/bmjopen-2019- 031886). Received 29 May 2019 Revised 16 August 2019 Accepted 21 August 2019 For numbered affliations see end of article. Correspondence to Dr Claire Hulme; C.T.Hulme@exeter.ac.uk Original research © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. Strengths and limitations of this study ► While participant numbers are modest, staff were purposively sampled across a range of skill mix so similar numbers were observed. ► Patients and ‘non-patients’ were recruited—the lat- ter to include people who may not engage with local dental care services. ► There will inevitably be a degree of bias given that all the practices were self-selected. ► The model of access was broadly sustained in the data but might be enhanced by greater conceptual clarity. ► Although the new practices increased access, fur- ther work is required to understand how best to promote and encourage appropriate dental service attendance. ABSTRACT Objective This study aimed to describe stakeholder perspectives of a new service delivery model in primary care dentistry incorporating incentives for access, quality and health outcomes. Design Data were collected through observations, interviews and focus groups. Setting This was conducted under six UK primary dental care practices, three working under the incentive-driven contract and three working under the traditional activity- based contract. Participants Observations were made of 30 dental appointments. Eighteen lay people, 15 dental team staff and a member of a commissioning team took part in the interviews and focus groups. Results Using a qualitative framework analysis informed by Andersen’s model of access, we found oral health assessments infuenced patients’ perceptions of need, which led to changes in preventive behaviour. Dentists responded to the contract, with greater emphasis on prevention, use of the disease risk ratings in treatment planning, adherence to the pathways and the utilisation of skill-mix. Participants identifed increases in the capacity of practices to deliver more care as a result. These changes were seen to improve evaluated and perceived health and patient satisfaction. These outcomes fed back to shape people’s predispositions to visit the dentist. Conclusion The incentive-driven contract was perceived to increase access to dental care, determine dentists’ and patients’ perceptions of need, their behaviours, health outcomes and patient satisfaction. Dentists face challenges in refocusing care, perceptions of preventive dentistry, deployment of skill mix and use of the risk assessments and care pathways. Dentists may need support in these areas and to recognise the differences between caring for individual patients and the patient-base of a practice. INTRODUCTION Commissioning of National Health Service (NHS) dentistry in England is moving away from volume-based contracts with payment for units of dental activity (UDA) to an approach that rewards quality and oral health improvement alongside activity. 1 Payments recognise prevention and reward the contri- bution of the dental team to improved oral health, reflected in patient progression along care pathways, adherence to nationally agreed clinical guidelines and the achieve- ment of expected outcomes. 1 The Depart- ment of Health and Social Care (DHSC) dental contract reform programme opened a series of pilots in 2011, subsequently followed by ongoing prototype systems, to explore a shift from treatment and repair to prevention and improved oral health via a new clinical pathway and new remuner- ation models. 2 3 While the impact of these contracts on process has been investigated, limited evidence exists on their effect on oral on February 23, 2022 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2019-031886 on 3 October 2019. Downloaded from