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

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 influenced 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 identified 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.