Promoting access to dental care in South London: adult patients’ perspectives

Access to basic health services is a fundamental human right (World Health Organization 2013) and further emphasised as playing a role in addressing global inequalities (Marmot 2008). Access to health care is a complex and multi-dimensional concept and as a result there are many definitions. Guay (2004) considered access to be a supply and demand issue, encompassing both the availability of dental care as well as the willingness of the patient to seek care. More recently Harris (2013) proposed the construct of dental access as involving the following four concepts: opportunity for access, realised access (utilisation), equity and outcomes. Gulliford and Morgan (2003) describe the factors influencing access as multifaceted and the importance of research on barriers to access. Barriers to dental care have been well researched nationally (Finch et al. 1988; Hill et al. 2013; Kelly et al. 2000) and locally (Borreani et al. 2008, 2010), with Borreani et al. (2008) classifying barriers in older adults as ‘active’ or ‘passive’: active barriers include availability, accessibility, cost, fear and features of the dentist, whereas lack of perceived need is a passive barrier. Despite the research into barriers, there is a relative paucity of research on initiatives to improve the uptake of dental care (Gilbert et al. 2009), and the published literature tends to relate to small local initiatives or policy initiatives (Anderson and Morgan 1992).

In England, the uptake of dental care decreased between 2006 and 2008 following the introduction of a new dental contract in April of 2006. Steele (2009), in a review commissioned by the Secretary of State for Health, reported in 2009 that up to 24% of the population had difficulty in locating an NHS dentist, and 20% perceived poor quality of care from NHS dentists. A national ‘Dentistry Watch’ survey conducted in 2007 on 5212 patients found that 20% avoided treatment because of cost, while 50% of all NHS patients found NHS dental charges confusing (Commission for Patient and Public Involvement in Health 2007). It was evident that access to NHS dentistry needed to be improved, and this became a political imperative supported by resources (Department of Health 2009, 2011; Steele 2009). Locally, NHS Primary Care Trusts [PCTs] used the additional resources provided to increase the uptake of NHS dentistry to implement a series of initiatives to address dental uptake in metropolitan inner city area during 2009/10. Individual practices were encouraged to form targets and plans to improve the uptake by dental patients and increase the provision of dental care, which has then been compared with national data. A range of initiatives was funded by local PCTs to improve access including banners, advertisements in local newspapers, advertisements on buses and bus shelters, free toothpaste/-brush packs for new patients and cinema advertisements, as listed in Tables 2 and 5. Also some individual practices had further initiatives funded, including free check-up vouchers for new patients and a texting service to remind patients of appointments. Information-based initiatives to improve the uptake of dental care have been evaluated and shown to provide insight into both practitioner and patient perceptions, but with little impact on service uptake (Anderson and Morgan 1992). In a similar way the current study examined the impact of dental access initiatives on patients’ awareness and perceived influence in patients in inner city metropolitan areas of London. These boroughs have socially deprived and ethnically diverse populations, with poor dental uptake patterns (Gallagher et al. 2010). At the time, health service data suggested that 56% of the adults in Lambeth, 51% in Southwark and 59% in Lewisham had utilised an NHS dentist in the preceding 24 months based on the local resident population (NHS Digital 2009).

To explore the views of adult patients attending primary dental care in inner city practice on initiatives to raise awareness and improve dental access.

Dental practices with, and without, extended NHS capacity (referred to as extended and regular practices in this article) were identified and practice principals invited to participate in this research. NHS contracts were across the three boroughs of Lambeth, Southwark and Lewisham in South London. The study was designed to have a power of 80%, at the 5% significance level, to detect standardised differences of 0.25 and above between extended and regular contracts, for which a total of 256 respondents in each category were required. Therefore, 60 patients were requested per practice to account for a possible 25% non-response rate.

A questionnaire was developed for adult patients (16 years and over) attending participating dental practices. The self-completed questionnaire explored key areas: reasons for dental attendance; awareness of the range of local service initiatives to promote primary dental care during the past year; whether these initiatives were perceived to influence their behaviour to access NHS dental care; barriers to dental care; patient demography. The patient questionnaire was based on previous research: a study on marketing dentistry in Dudley by Anderson and Morgan (1992); the national adult dental health survey questionnaire (Kelly et al. 2000; NHS Digital 2011b); the Commission for Patient and Public Involvement in Health (2007).

The survey instrument consisted of 15 questions in three sections:

A five-point Likert scale ranging from ‘definitely yes’ to ‘definitely no’ was used as responses to the questions around ‘awareness’ of initiatives and the reverse of the scale was used on the questions around ‘influence’ of initiatives.

The patient questionnaire was tested through face-to-face piloting in two dental practices in Lambeth and Lewisham. The respondents were invited to report whether the questionnaire was understandable, and acceptable, as advocated by Bowling (2002). The questionnaire was found to be generally easy to complete and acceptable by the patients. However, based on patient feedback, it was necessary to reword the question relating to the influence of initiatives as these initiatives came, went and varied across the boroughs. It was clear that patients were interpreting the question on whether these had influenced them to include would have used them. Thus the question was amended to explore whether they had or would have changed their behaviour towards access to NHS dental care. This was undertaken with the view that the findings would inform future initiatives.

The questionnaire was administered by the practice staff to adult patients attending the participating practice in late spring 2010. There was a sign posted at the entrance and in the waiting area identifying that a survey was taking place. Adult patients were given an information sheet about the evaluation and asked if they would like to participate. Those who accepted were asked to complete the questionnaire survey in the waiting room and place it in a designated, sealed box at the reception for the research team; anonymity was assured. The researcher (SHM) made regular visits throughout the week to the participating dental practices to check the progress of the survey and collected completed questionnaires at the end of the week. Paper and computer records were coded by dental practice. The researcher was blind to the nature of the practice contract and unblinding did not occur until analysis was completed.

Quantitative analysis was undertaken using SPSS v21 following data input onto a computer. Descriptive, univariate and factor analyses were conducted to ascertain the awareness of initiatives and their influences on the patients based on socio-demography. Correlation between awareness and influence was measured using Pearson’s correlation coefficient. Significance was taken as ≥0.05.

This research provides insight into the multiple initiatives to improve access to dental care across three inner city boroughs in London and their influence on patients. Vouchers for free treatment were perceived as the most influential option according to patients attending during this period; this is in line with the suggestions made by Boyce et al. (2008), who suggest financial incentives are the most effective in influencing individual choices and are likely to be most effective when used as one element of a wider programme to promote long-term behaviour change. Our findings suggest that location was reported as the most influential in patient’s choice of practice, particularly amongst men; women on the other hand were more likely to attend a practice based on its reputation. Gender-based differences are increasingly recognised as important considerations in developing and providing health services (Department of Health 2008).

Adult patients attending primary dental care in three inner-city metropolitan boroughs, during a period when dental care was actively promoted and uptake increased, appear generally to have a long-term relationship with their dental practice. Certain initiatives are perceived to facilitate access more effectively in sub-sections of the populations with financial incentives appearing to have the most attractive influence amongst this socially deprived community, and dental advertisements least. On the other hand, many adult patients certainly appear to be aware of banners located outside dental practices and of dental advertisements in magazines; however, their role in influencing attendance is debatable. Overall it is apparent that dental practices should clearly display their status, charges and emergency helpline numbers for NHS dental care in support of patients.