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What is quality primary dental care?

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What is quality
primary dental care?
S. Campbell1 and M. Tickle*2
In the first paper of a series exploring quality in primary dental care a definition for quality in dentistry is sought. There is
a little agreement in academic literature as to what quality really means in primary dental care and without a true under-
standing it is difficult to measure and improve quality in a systematic way. ‘Quality’ of healthcare in dentistry will mean
different things to practitioners, policy makers and patients but a framework could be modelled on other definitions within
different healthcare sectors, with focus on access, equity and overall healthcare experience.
INTRODUCTION
The quality of healthcare is a complex con-
cept. Although all stakeholders want to pro-
mote, provide or receive quality dental care
our understanding of this concept in den-
tistry is underdeveloped. There is no agreed
or unique definition of quality of care in
primary care settings.1-4 This applies more so
to dental practice than to medical practice,
as most of the literature and evidence base
for defining quality of care in primary care
settings comes from general medical prac-
tice and management of healthcare systems,
rather than directly from oral healthcare set-
tings. Dentistry, in the UK or internationally,
whether it is provided through state funded-
services, privately or via insurance schemes,
has no agreed understanding of, or indeed
much literature on, what constitutes high
quality care.
This paper, the first in a series of three,
discusses the notion of quality of care in
dentistry, set against the context of exist-
ing definitions of quality of care generally
1
Professor of Primary Care Research, Population Health
Research Institute, affiliated to the School of Dentistry,
The University of Manchester, Higher Cambridge Street,
Manchester, M15 6FH; 2Professor of Dental Public
Health and Primary Care, School of Dentistry,
affiliated to Population Health Research Institute,
The University of Manchester, Higher Cambridge Street,
Manchester, M15 6FH
*Correspondence to: Professor Martin Tickle
Email martin.tickle@manchester.ac.uk;
Tel 0161 275 6610
Refereed Paper
Accepted 9 May 2013
DOI: 10.1038/sj.bdj.2013.740
© British Dental Journal 2013; 215: 135-139
BRITISH DENTAL JOURNAL VOLUME 215 NO. 3 AUG 10 2013
in other healthcare services. In so doing it
addresses what is known about quality in
primary dental care and whether quality,
as a concept in dentistry, differs from other
healthcare services. The paper will outline
the attributes of quality and the differ-
ent perspectives of stakeholder groups
(public, patients, dentists and dental care
professionals (DCPs), commissioners, and
policy-makers) and comment on the policy
implications for a clear agreed definition
of quality. It will end by describing how
a framework for defining quality for den-
tistry could be developed and some of the
key concepts that it would include. The
second paper in this series will discuss how
to measure quality and the final paper in
the series will look at quality improvement
within primary dental care.
The starting point for any attempt to
improve quality is to get an agreed under-
standing of what this concept means, usu-
ally through a clearly stated definition. As
Donabedian asserted correctly in 1985 ‘We
cannot assess quality until we have decided
with what meanings to invest the concept.
A clear definition of quality is the foun-
dation upon which everything is built’.5
Any such definition must be grounded in
a conceptual framework that describes the
totality of quality of primary dental care,
this will determine which aspects of care
are included in a set of any quality indica-
tors and what they measure. Once you can
measure quality of care acceptably, validly
and reliably you can start to improve it.
© 2013 Macmillan Publishers Limited. All rights reserved.
IN BRIEF
• Points out that there is no agreed
definition for quality in dentistry.
GENERAL
• Suggests that without an agreed
definition it is difficult to measure quality
and therefore difficult to improve quality
in a systematic way.
• Stresses the need for a conceptual
understanding of the concept of
quality to support the development of a
definition and measuring instruments.
DIFFERENT PERSPECTIVES
OF VARIOUS STAKEHOLDERS
There are various definitions of healthcare
quality depending on the perspective from
which healthcare is viewed.2,6,7 For primary
dental care the stakeholders are the pub-
lic, patients, dentists and DCPs, commis-
sioners and policy makers. Importantly, it
may not be possible, or indeed desirable,
to find an agreed definition that would
satisfy all users of a definition. Moreover,
it cannot be presumed that one stakeholder
group’s perspective necessarily represents,
or indeed, takes precedence over another
group’s views. For example, health profes-
sionals may focus on professional stand-
ards and technical aspects of care, patients
may concentrate on communication skills
and continuity of care and managers may
prioritise efficiency and, increasingly, the
outcomes of care. Even if the same aspects
of care are assessed an indicator can be
valued differently by different stakeholder
groups, for example, health professionals
and managers and patients are likely to
value efficiency differently.8
THE BIGGER PRIMARY
CARE PICTURE
Dentistry is predominantly a primary care
service. There are therefore many paral-
lels between general medical practice and
general dental practice. The Declaration of
Alma Ata in 19789 reaffirmed the World
Health Organisation (WHO) definition
of health and also defined the meaning
135
GENERAL
of primary care, urging governments to
develop primary care and incorporate the
primary care approach into their health-
care systems. Worldwide evidence indi-
cates that the primary care approach leads
to better health outcomes for lower costs.10
Starfield11 identified four cardinal features
of primary care:
• First contact between the healthcare
system and members of the public
• Ongoing, person-centred care
over time
• Comprehensiveness – addressing all of
the commonly encountered needs of
the population
• Co-ordination or integration – referral
to specialists for patients who have an
unusual or uncommon condition.
Primary care is greater therefore than
merely the clinical treatment of patients
and quality is not confined to clinical out-
comes but also encompasses how a ser-
vice is organised and delivered according
to such pivotal features. When definitions
of quality have been considered in the lit-
erature there is an underlying assumption
that clinical care and the broader features
of a service are delivered by qualified,
competent and up-to-date practitioners
who recognise their own limitations and
draw appropriately on the strengths of
others.1 These assumptions are important
as they set minimum standards and con-
ceptually separate out quality from indi-
vidual professional under-performance
and misconduct.
DEFINING QUALITY OF CARE:
GENERIC, DIMENSIONAL,
INDIVIDUAL, POPULATION
Attempts to define quality of healthcare
basically fall in to two camps: generic and
disaggregated.2 The former seek to define
all aspects of quality in a single all encom-
passing (hopefully succinct) statement,
whereas the latter disaggregated defini-
tions seek to define separate and multiple
dimensions of quality.
Some definitions of quality have
embraced simplistic or generic state-
ments; for example, relating to the care
healthcare professionals would want to
receive if they themselves became sick.12
However, generic definitions are often of
limited practical value in terms of iden-
tifying key processes and outcomes and
136
‘Structure’ is not just about buildings and equipment, staff and skills, but also about the regulation and
contracting of healthcare.
‘Process’ refers to the mechanics of how a service is delivered, the interactions between users and the
healthcare system; in essence what is done to or with users. Campbell and colleagues prioritised two key
processes: clinical care and inter-personal care.2
‘Outcomes’ refers to the end points or consequences of care, both clinical effects and satisfaction with the
care received. Structure as well as processes may influence outcome indirectly or directly (see Table 1).
Fig. 1 Structure-process-outcome
Table 1 Dimensions of healthcare quality within the structure-process-outcomes model
Structural aspects of health care systems
Domain Dimension Examples of individual components
Resources Financial, personnel, buildings, equipment, informatics
Organisation Provider continuity, hours of operation, location,
Physical characteristics
of resources appointment systems, routine booking interval, waiting times
Management Administration; operational and strategic management
Skill-mix Skills/knowledge of individuals; disciplinary mix within team
Staff characteristics
Teamworking Team functioning; delegation, role‑substitution
Processes of care
Domain Dimension Examples of individual components of care
Problem/needs History taking; physical examination, diagnostic tests
Clinical care
definition and investigations
Can be considered for: Problem/needs Diagnosis/prescribing/procedures/operations/
acute/chronic/preventive management referral/coordination
Inter-personal aspects Problem/needs
Information exchange, communication
of care definition
Can be considered for: Problem/needs Understanding/professional-patient relationship/
acute/chronic/preventive management advice/reassurance
Outcomes
Domain Dimension Examples of individual components of care
Freedom
Health status Functional status
from disease
Comfort Symptom relief
Longevity Quality of life year
User evaluation Satisfaction Access
Enablement Coping
HRQOL Self-esteem
trade both sensitivity and specificity for groups and even people within the same
generalisability. Attempts to develop all- stakeholder group often disagree about the
embracing definitions of quality lead to essence of quality. The concept of quality
the production of meaningless and blunt is therefore most frequently proposed and
measures vulnerable to contamination by defined as a multidimensional one.7,13,14
a wide range of factors at both the individ- Maxwell suggested six  dimensions of
ual (patient) and environmental (society) quality (access, effectiveness, efficiency,
levels: ‘There is a danger of enlarging the equity, relevance and social acceptability)
definition of quality so much that it loses and Donabedian suggested seven dimen-
distinctiveness and analytic utility, becom- sions (acceptability, effectiveness, efficacy,
ing almost a slogan which means nearly efficiency, equity, legitimacy and opti-
anything anyone chooses it to mean’.6 mality). Such dimensions or attributes, in
Generating an all-encompassing definition whatever combination or taken in isola-
is also difficult because of the contextual tion, constitute a definition of quality of
nature of quality  –  different stakeholder care.15 Most frequently these dimensions
BRITISH DENTAL JOURNAL VOLUME 215 NO. 3 AUG 10 2013
© 2013 Macmillan Publishers Limited. All rights reserved.

or attributes are placed within the struc-
ture-process-outcome model advocated by
Donabedian (Fig 1).6,13
The triad of structure, process and out-
come was intended to be ‘approaches to the
acquisition of information about the pres-
ence or absence of the attributes that con-
stitute or define quality’.6 In other words, it
facilitates the measurement of quality and
will be considered with some of the techni-
cal issues concerning measurement such as
validity and reliability in second paper of
this series. However, simply listing attrib-
utes or dimensions does not provide an
adequate definition of quality in itself,
as simple listing can describe properties
without inherent value.16 As such, a multi-
dimensional approach within a generic
definition has been proposed.2 In addition,
initial generic definitions have evolved
into multidimensional definitions. For
example the Institute of Medicine defined
quality in 1990  as ‘The degree to which
health services for individuals and popu-
lations increase the likelihood of desired
health outcomes and are consistent with
current professional knowledge”,17 which
later evolved into identifying dimensions
of safety, effectiveness, patient-centered-
ness, timeliness, efficiency and equity.18
There is significant overlap in the
dimensions within published definitions
of quality of healthcare, with a prominent
focus on integration, access, effectiveness,
equity and efficiency as key attributes of
health care quality.2 Patients may trade
off one  attribute for another depending
on their needs at any one time; for exam-
ple, trading continuity of care (a patient
seeing their regular dentist for a routine
check-up) and speed of access (the patient
wanting to see any available dentist if they
are in pain). This trade-off between access
and continuity has been found in other
studies19 and can be positive when patients
receive timely and effective care20 but neg-
ative if they ‘accept a decreased value of
one attribute for an increase in another’,21
for example persistent unavailability of the
dentist a patient usually sees in return for
walk-in pain relief.
Quality from the perspective of the
individual patient should be considered
separately from the perspective of the
general public or the practice-population.
Campbell and colleagues summarised
quality for individual patients as; ‘whether
BRITISH DENTAL JOURNAL VOLUME 215 NO. 3 AUG 10 2013
individuals can access the effective care
they need with a patient-centred focus on
maximising health outcomes’, but that this
has to be set against a population con-
text that feeds in the concepts of equity
and efficiency.2 This has been described
as simplistic,22 but others have emphasised
the dual foci of holistic, personalised care
for individuals that is provided equitably
at a population level.1,23 There is also a
difference between horizontal equity:
care that is equally accessible and equally
effective for patients with the same degree
of illness; and vertical equity: care that
provides better access for patients with
greater need.2,24
TRUST AND ACCOUNTABILITY
All patients presenting to any dental prac-
tice anywhere in Europe or worldwide have
a right to safe, quality care. This requires
a transparent definition of the attributes
and measures to enable quality assurance,
that is to objectively demonstrate that high
quality, safe care is being provided.25 To do
this requires a focus on population level
measures using quality control (a process
to maintain standards) but this provides
values for the average patient rather than
individual patients. In order to provide
personalised, patient-centred care at the
individual level, there is also a need for
clinical autonomy and trust within a prac-
titioner-patient therapeutic relationship.26
This is because there is no such thing as an
‘average’ patient.4,25,27,28 As such, maximis-
ing quality of care for populations should
not be at the expense of jeopardising the
therapeutic relationship between indi-
vidual patients and health practitioners.2,25
Heath has described how ‘biomedical
science has made prodigious advances by
viewing the body as a standardised object’
and while ‘this works relatively well in
some aspects of specialist practice, it works
much less so in general practice’ because
of ‘the limitations of treating human indi-
viduals as interchangeable units’.28 General
medical practitioners are often presented
with ‘unexplained symptoms and the com-
plex mess’,4 which is the day-to-day reality
of the immensely diverse problems pre-
sented by successive individual patients,
often with multiple morbidity.25 Therefore,
within general medical practice quality
of care as a concept has most meaning
and is at its purest as a patient-centred
© 2013 Macmillan Publishers Limited. All rights reserved.
GENERAL
approach related to individual patients;
although this must be placed in the context
of providing healthcare for populations.2
However, the measurement of quality is
most often reported as ‘average’ patients
within a population.2,25 How do these fea-
tures apply to quality in primary dental
care? Is it about personalised individual
care or is it more concerned with the bio-
medical treatment of standardised prob-
lems using predetermined care pathways?
Is it more about access and efficiency?
WHAT IS NOT KNOWN ABOUT
QUALITY IN DENTISTRY AND
HOW DOES QUALITY IN
DENTISTRY DIFFER FROM
OTHER HEALTHCARE SERVICES?
There is a traditional, poorly articulated
notion that quality in dentistry is exem-
plified by complex, expensive care with a
significant cosmetic component for exam-
ple, crown and bridgework or implant-
retained prostheses. This perception was
reinforced when the House of Commons
select committee29 raised concerns about
the quality of care delivered as a result in
the drop in the number of complex courses
of treatment following introduction of the
2006 NHS contract.30 This simplistic view
of quality reflects the underdeveloped aca-
demic literature on the subject in dentistry.
There is no agreed definition of quality
in dentistry22,31 although this hasn’t pre-
vented measures of different aspects being
developed and used.32-34 These measures
have largely focused on clinical aspects
of care, but have also drawn on some of
the work undertaken in the wider medi-
cal literature; naturally primary medical
care is seen as the most comparable field
to primary dental care. However, dentistry
differs from primary medical care in a
number of specific and significant ways,
which will influence the views of stake-
holder groups on how quality in dentistry
is perceived.
In general medical practice a large pro-
portion of patients seek care sporadically
as a result of experiencing symptoms, and
in dentistry a majority of patients attend
asymptomatically and on a regular basis.
Continuity of care is therefore important as
well as customer satisfaction to encourage
repeat attendance.
Dentistry is primarily a surgical discipline,
whereas general (medical) practitioners
137
GENERAL
(GPs) are predominately diagnosticians,
coordinators of care for long-term condi-
tions and gatekeepers to specialist care. This
has consequences; dental care is frequently
associated with pain and anxiety in popular
consciousness and therefore how pain and
anxiety are managed will have a significant
influence on patients’ views of the quality
of care provided.
Dentistry is predominantly concerned
with just two  diseases, whereas general
medical practice is confronted with a
much wider range of physical and psy-
chological conditions and often multiple
co-morbidities. Also many of the diseases
general medical practice is concerned with
are potentially more serious in nature.
Misdiagnosis, poor patient management
and clinical errors can therefore have seri-
ous or even fatal consequences. Therefore,
patient safety has a comparatively greater
significance within the overarching con-
cept of quality in medical practice than in
dental practice.
In the UK, care provided by general
medical practices is free at the point of
delivery whereas primary dental care,
whether in the public or private sector,
levies significant charges that are directly
linked to the care provided. The clinician
as part of the informed consent process
engages in a discussion with the patient
not only about clinical care but also about
treatment charges and this produces a dif-
ferent dynamic between patient and den-
tist than between patient and GP.
Many of the treatments provided by
general dental practitioners (GDPs), espe-
cially in the private sector, are primarily
cosmetic in nature and secondarily asso-
ciated with treatment of disease, whereas
GPs have a prime focus on treatment and
management of disease. This difference in
emphasis again changes the relationship
between clinician and patient, with the
dental patient more likely to adopt atti-
tudes associated with a customer rather
than a patient.
In the NHS the way GPs and GDPs are
paid is also very different. Like dentists,
NHS funding of GPs is largely practice-
based. Medical practices receive weighted
capitation payments, which generally
make up about half of their funding. In
addition they receive payments for pro-
viding evidence-based care primarily for
patients with chronic conditions such as
138
hypertension and diabetes through the
Quality Outcomes Framework. They receive
additional funding for providing optional
enhanced services. Critically they receive
premises payments, which vary according
to the value of the premises as determined
by the district valuer; their information
technology costs are also covered by the
local NHS. Contrast this with the way
English GDP practices are currently remu-
nerated, in which all costs (staff, premises
and consumables) are met from 12 fixed
monthly payments dependent on hitting
activity targets. Remuneration arrange-
ments have an important influence on
quality and are critically important if qual-
ity improvement is to be incentivised.35,36
Skill mix is more widely developed and
used in general medical practice compared
to general dental practice. There have been
recent calls to expand skill mix and the
GDC has recently removed its barrier to
direct access to some dental care profes-
sionals (DCPs).37 We have little understand-
ing of the impact of such developments on
the various domains of quality.
Although these differences will perhaps
not change the relevance of the fundamen-
tal domains of quality to dentistry, they
will influence the relative importance of
each domain as viewed by the different
stakeholder groups. It is therefore impor-
tant that dentistry does not just ‘lift and
shift’ the approach to quality developed
by primary medical care, rather something
bespoke and fit for purpose is required.
The Steele review38 advocated a stand-
ardised assessment of patients; categorisa-
tion of their disease risk and the care they
receive delivered according to evidence-
based care pathways. This approach to care
is currently being piloted. In such a system
can personalised individual care be main-
tained as a key component of quality or will
a more prescribed, biomedical approach to
treatment of standardised problems result
in more effective care and improved qual-
ity? Will a new capitation-based remu-
neration system deliver equitable access
and value for money? Policy makers will
need to weigh up the relative merits of these
potentially competing attributes to shape a
service that is focused on quality.
POLICY PERSPECTIVE
Following the Darzi39 report of the last
government, which called for quality to be
BRITISH DENTAL JOURNAL VOLUME 215 NO. 3 AUG 10 2013
© 2013 Macmillan Publishers Limited. All rights reserved.
a key organising principle of the NHS, the
current government’s NHS white paper40
seeks to promote a patient-focused, clini-
cally-led, outcomes-driven NHS. The NHS
constitution41 published by the previous
government and supported and updated by
the current government lists as one of its
seven guiding principles; ‘The NHS aspires
to the highest standards of excellence
and professionalism – in the provision of
high-quality care that is safe, effective and
focused on patient experience’. So quality
is not going to go away and will touch
every service provided by the NHS and by
extension patient expectations will rise
and have an impact on care provided in
the private sector. In England the first steps
have been taken to incentivise quality in
the pilots for a new dental contract and the
development of a Dental Quality Outcomes
Framework (DQOF).34 The DQOF is a start
to the process of incentivising quality, we
don’t know if it reflects all of the impor-
tant elements of quality or, importantly,
if the indicators included are valid and
reliable measures of quality. It will need
to be refined through rigorous academic
input. It is well accepted that policy and
research move at different paces and there
has been pressure to rapidly produce qual-
ity outcome measures for dentistry for the
new contract pilots. However, this does
not preclude the commissioning high
quality research to inform the evolution
of the DQOF to provide confidence to all
stakeholders that it actually does what is
expected of it.
DEVELOPING A FRAMEWORK
FOR DEFINING QUALITY
FOR DENTISTRY
The general practice QOF was first pro-
duced and introduced in 2004.42 In some
ways dentistry is currently in a similar
position to primary medical care at that
time. However, the GP QOF has since
been refined and validated through a
high quality, rigorous research and test-
ing programme.8 Dentistry must follow the
same approach from the start; this issue is
too fundamental and too important to be
based on opinion, anecdote and expedi-
ence. A conceptual model for quality in
dentistry needs to be built based on the
dental literature and drawing on the wider
healthcare literature. No doubt domains
such as service organisation, including

access, clinical effectiveness, patient safety
and patient experience will be included
but we need to start with principles and
supplement the review literature by col-
lecting empirical data to fill in the con-
siderable gaps. Only when we have this
strong theoretical base with a well-defined
typology specific to dentistry will we be
in a position to develop valid measuring
instruments.
CONCLUSIONS
Caper suggested that efforts to define the
term ‘quality’ should be abandoned in
favour of the identification and meas-
urement of its components.43 However,
without an agreed conceptual framework
underpinning these components they lack
value and a link to stakeholder experi-
ences and therefore their credibility can
be questioned. Moreover, without a clear
understanding of quality, how to measure
it and improve it, there is a risk that dental
services will not provide value and fail to
improve quality.
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