Dental Quality Improvement

The NHS contract requirements in Scotland ask dentists to complete equality and diversity on-line training as part of the Quality Improvement requirement. It’s useful to consider how equity interacts with quality improvement activities.

Don Berwick and colleagues in the US suggested that health systems should focus on improving the experience of care, improving the health of populations, and reducing per capita costs of health care – i.e. better care, better health, better value. This became known as the ‘Triple Aim’ and was widely accepted. Clinicians argued, however, that none of this should be at the expense of staff, and a fourth aim – improving the quality of life for service staff – was added, turning a triple aim into a quadruple aim.

The Institute for Healthcare Improvement then added a fifth aim, advancing health equity. Health equity does not suggest that everyone will have equally good (or bad) health – that’s obviously impossible. Rather, it argues that societies should work towards a situation where everyone should have the potential to achieve their best health possible, and that this should not be prevented by social circumstance or other socially determined matters (race, poverty, disability, LGBTQI+ status, etc.).

Every dental team member knows from experience that dental health is not evenly distributed. That’s true across the UK (see, for example, evidence in Scotland, and England ), the US, and worldwide. Many of the factors that influence dental health are well outside the control of a dental service, however well meaning. There’s a limit to how much influence we can have on societal levels of poverty, education and controls on advertising, for example.

Access to dental services is a big issue in the UK just now, and we know that access to dental care affects dental health, or there wouldn’t be much point in dental services. Practices don’t control dental payment systems but many practices with limited NHS capacity will be having difficult discussions about who to prioritise for their NHS spaces.

The same environment that produces current pressures on NHS services – staffing, recruitment, retention, quality of life and funding – also puts pressures on service quality. Many teams will work on issues to improve flow, reduce waiting times and cope with recruitment problems by multi-tasking and delegating (multi-skilled working, in quality improvement jargon). This can bring substantial benefits, but it’s also possible to worsen things for some groups of patients. This is where there is a live link between equity and quality improvement. Teams don’t want to improve one aspect of their service at the expense of making things worse for some of their patients, or their staff.

Looking at impact on patients, examples can include using apps or on-line systems to book appointments, when some patients may not be able to manage them, because of age or disability; creating patient information materials in only one language when you have a multi-ethnic patient population; decreasing the time available for appointments when some patients with anxiety might struggle, creating a new process that puts additional pressure on some staff members, and so on.

This doesn’t mean that changes can’t be made, but it makes sense for the dental practice or dental services team to take careful stock of any changes they are making.

The team can ask:

• Is there any obvious downside to the planned change that may affect one or more groups of patients?

• What do patients think about the plan?

• Is it worth creating a balancing measure to keep track of the potential risk?

• If there is a predictable risk to any patient group, is there anything the practice can do to eliminate or minimise it?

For teams and services that want to look at equity in detail, there are detailed resources available from the Institute for Healthcare Improvement. In the meantime, thinking about equity when making changes is a good way to start.

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