PRACTICE

health policy

Primary and secondary dental care:

the nature of the interface
A. J. Morris1 and F. J. T. Burke2

tals and this may rise further with the devel-

Specialist dental services are scarce resources and are often opment of specialised services with Dental
oversubscribed. A key element is how these services relate to their Bodies Corporate (DBCs). The interface
between primary (PDC) and secondary
referral base, in other words the interface between primary and
dental care (SDC) therefore, whilst sharing
secondary dental care. Dentistry has several unique qualities when some common features with medicine, is
compared with medicine and the nature of the interface between likely to be different because of the differing
primary and secondary dental care is consequently very different to nature of both primary and secondary den-
the medical interface, whilst apparently sharing common features. tal care from their medical counterparts.
This paper examines the nature of the
This paper examines the nature of that interface, the drivers for
interface and the drivers for patient flow
patient flow between services and outlines the properties of an ideal between services as a precursor to dis-
interface. This model can then be used as a way of describing some of cussing how the interface might be
the problems facing specialist dental services and of assessing any improved.
proposed solutions.
The features of the interface
The interface between primary and
secondary dental care displays three key fea-
entistry is essentially a primary care tion of care is provided outside hospitals tures; interdependence, integration and
D discipline insofar as the vast majority
of patient care takes place in community
(where it often attracts patient charges)
and secondary care is more likely to be
complexity.

settings, is restricted to simple procedures on an outpatient basis. In addition, Interdependence

and is provided by ‘generalists’ who in the liaison with secondary care forms substan- Primary and secondary care providers are
main hold, or aspire to hold, a long-term tially less of a general dental practitioner’s dependent upon each other. On the one
relationship with their patients.1 In medi- (GDP’s) working day than it does for a hand the PDC provider needs somewhere to
cine, a key aspect of recent health policy has general medical practitioner. The routine refer patients who need treatment outside
been to drive the provision of a greater pro- work of many GDPs includes items of care his or her knowledge and competence; and
portion of care in community settings by which has at times been regarded as spe- may need support for patients whose treat-
generalists and thus reduce the referral rate ment might be provided within primary
to secondary care. This policy has had major care but for whom specialist advice is
implications for medicine in the last In brief needed to facilitate this. SDC providers are
decade2,3 and is a key element in the new • This paper summarises the published reliant upon PDC as the main source of
NHS Plan.4 work describing how primary and their referrals (which in turn generate
In dentistry most care is provided by gen- secondary dental care relate to each research and training material for under-
other (interface)
eralists and patients are rarely referred graduate and postgraduate students) and
• A model describing the properties of an
to specialists, though referral rates are ideal interface is suggested need an outlet for the return of completed
reported to have risen greatly in recent years • This model can be used to help cases for routine maintenance care.
and are likely to continue to do so. Thus, as in categorise perceived problems with the Changes on either side of the equation or
medicine, secondary dental care providers interface and suggested solutions shifts in the location of the interface can
and commissioners experience problems in affect both sides and a wide range of factors
managing demand. Dentistry differs from might affect the flow of patients between
medicine, however, in that a larger propor- PDC and SDC (Fig. 1) and between differ-
cialised, for instance orthodontics and ent SDC providers.
endodontics. Some forms of care are often
1 Lecturer in Dental Public Health 2 Professor of
provided by academics with honorary NHS Integration — co-operation,
Primary Dental Care
*Correspondence to: John Morris, School of Dentistry,
contracts working within dental hospitals; communications and coordination
The University of Birmingham, St Chad’s Queensway, in some cases there might only be a single Co-operation and good communications
Birmingham B4 6NN consultant in a particular specialty for a are essential for a successful interface.
email: [email protected] whole NHS region. Lastly, a significant Both sides need to be clear about what the
REFEREED PAPER
Received 03.04.01; Accepted 20.07.01 amount of secondary dental care is pro- other is requesting or proposing, particu-
© British Dental Journal 2001; 191: 660–664 vided by non-consultants outside of hospi- larly when the treatment requires them to

660 BRITISH DENTAL JOURNAL, VOLUME 191, NO. 12, DECEMBER 22 20001
 PRACTICE
health policy

Drivers Inhibitors

the specialist provider

May be influenced by
Low waiting times High waiting times
Super-specialist Prioritising
skills decisions or
Practitioner protocols
demand Secondary Care Access problems

Provider

Outside the influence of

the specialist provider
Need Patient demand
Patient demand Health policy
Clinical guidance
Health policy
Treatment within
Clinical guidance primary care

Fig. 1 The drivers and inhibitors for referral to secondary dental care

co-ordinate their efforts. In their guid- were a proposed treatment plan, the date of trol the process. In addition, different parts
ance for practitioners referring to consul- the visit and feedback on the appropriate- of the country will find different local solu-
tant orthodontic services, Ferguson, ness of referral. tions to their problems; what apparently
Langford and Davenport5 recommended The coordination of primary and sec- works in one area will not necessarily work
that practitioners bear in mind the pres- ondary care services is less amenable to in another. The question then is what fac-
sures under which such services operate guidance and probably presents the greatest tors act as catalysts and barriers for referral?
and consider a number of factors when challenge. In a study comparing referrals to These are likely to be multiple (Fig. 1), some
making a referral. Some services have specialist orthodontic practitioners with a acting in the short term and capable of
introduced referral guidelines to assist consultant-led unit9 it was found that refer- being manipulated by stakeholders, others
decision-making by referring practition- ring dentists did not discriminate between tending to act in the longer term.
ers, though there are few completed stud- the different services, the two specialist
ies evaluating their effect.6 groups in effect competing rather than
Drivers for referral
Despite the influx of IT into dental prac- complementing each other.
tice, letters are still the main means of com- Population need and demand
munication. In a survey of dental Complexity If the role of healthcare services is to meet
consultants,7 a number of features of an Like its medical counterpart, the dental need, then changes in the levels of some
ideal referral letter were identified, with lit- interface is complex, though it can some- conditions will obviously be a significant
tle variation between specialties including a times appear to be composed of simple driver for referrals to secondary care.
clear statement as to why a referral is being issues, particularly when waiting list prob- National epidemiological surveys of chil-
made, whether or not malignant disease is lems are being discussed. Secondary care dren11,12 demonstrate falling dental caries
suspected and an indication of the urgency services are subject to a range of influences experience and the latest adult dental health
of the referral. However, the advice is not all driving the referral rate and have a number study13 confirms a continued reduction in
one-sided; in a survey of 268 general dental of options for managing increased referrals. the prevalence of total tooth loss, though
practitioners and 13 orthodontic consul- How they choose to manage such pressures improvements in tooth retention in middle
tants8 GDPs had several points to make has impacts both on other services and on aged and older adults are mainly in terms of
about what they valued in reply letters from the forces driving referral. It is worth restored rather than sound untreated teeth.
consultants following the initial patient remembering that, as in medicine10 there From this we might suppose that referrals to
visit. Apart from details allowing patient are likely to be differing perceptions as to specialists should have reduced over the last
identification, the contents scoring highest which professional groups are able to con- twenty to thirty years. The relationship
BRITISH DENTAL JOURNAL, VOLUME 191, NO. 12, DECEMBER 22 20001 661
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between population changes in disease ate referrals such as not referring people for Dental Reference Service, a viewpoint
experience and the demand for specialised orthodontic treatment when they demon- which was agreed with by three
services is complex however; falling disease strated poor self-care. A minority reported quarters of respondents in the postal ques-
experience often comes alongside raised referring patients for treatment, not tionnaire part of the study. The predictabil-
public expectations for oral health and because they were unable to carry out that ity of the envisaged treatment was also
demand for a wider range of problems to be treatment but because that treatment was regarded as a factor; less predictable and/or
dealt with. For instance, falling child caries not a ‘practice builder’. Some respondents protracted treatment being less attractive.
levels have paralleled increased demand for thought that rising clinical standards were a In the case of general anaesthesia for
orthodontics. Public demand may be influ- factor in driving up referrals. Changes in dental procedures there is now a clear
enced by other factors besides need, such as guidance related to general anaesthesia directive from the CMO/CDO report on
information on services available, the media, were a common example given but some general anaesthesia and sedation16,17 which
personal contact with people who have also reported that they felt discouraged will have the effect of moving residual
experienced specialist care and of course from undertaking orthodontic treatment general anaesthetic provision into hospitals.
dentists themselves. Changes in disease because of increased scrutiny from the Lastly, primary dental care practitioners
levels therefore may be associated with both
positive and negative influences on referral
rates, acting both through the opportuni-
Table 1 Factors reported to be associated with variations in
ties for referral presented by the presence of
referral rate amongst primary dental care practitioners
disease and through changing patient atti-
tudes which are both a factor in and a con-
sequence of changing disease levels.
Factors associated with:
Primary dental care practitioner as
promoter and gatekeeper Higher referral rate Lower referral rate
The key factor in determining referral is
almost certainly the primary care practi- High levels of need amongst Low levels of need amongst
tioner in their ‘gatekeeper’ or filtering role. patients under care patients under care
PDC practitioners stimulate demand in
terms of identifying patients who would Older practitioner Younger practitioner
benefit from specialised care, in promot-
ing referral to the patient, and have a key Postgraduate education (improved Postgraduate education (improved
role in managing inappropriate demand. surveillance) selection)
Perhaps surprisingly, despite the differ-
ences between primary and secondary den- Reduced desire or ability to be Reduced ability or desire
tal care in terms of direct costs to patients, selective to screen patients
there is little evidence that this is a major
factor in referral, at least not for minor oral Remuneration system Remuneration system
surgery.14 (rewards referral) (rewards treatment)
PDC practitioners may be subject to a
number of influences when making refer- Clinical standards or Clinical support for dentists
ral, including past experience and training external scrutiny driving wishing to carry out advanced care
and their attitude towards certain condi- referral to specialists
tions. In addition there will be straightfor-
ward business decisions based around the
Management directives to Management directives restricting
perceived financial viability of treating cer-
refer certain categories dentists’ right to refer
tain conditions and the likelihood of a suc-
of patient
cessful outcome. In a qualitative study
involving general dental practitioners and
patients15 a variety of views about how they Short distance from Long distance from
related to specialist services were elicited. specialist provider specialist provider
Most recognised the services as scarce
resources which should not be abused and No advanced clinical skills Advanced clinical skills
reported taking steps to avoid inappropri-

662 BRITISH DENTAL JOURNAL, VOLUME 191, NO. 12, DECEMBER 22 20001
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health policy

may be increasingly guided towards referral

through clinical governance mechanisms or Table 2 Features of the ideal interface between primary and
advice from indemnity organisations. secondary care

Differences between primary dental care

(PDC) practitioners Ideal Quality Features
Variations in referral rates between different
practitioners, even when expressed as a
Equity All appropriate cases in the population are referred for
function of the number of patients under
specialist care
their care, are difficult to interpret. On one
hand a high referring practitioner may be
inappropriately referring cases which are No barriers to receiving specialist care once referred
well within their abilities. On the other hand
a low referral rate might be the result of a Seamless care All required treatment is available and accessible in
poor ability to identify patients who would either primary or secondary care services
benefit from specialist care. One obvious
explanation for variations amongst dentists Transition between primary and secondary care is
might be different levels of need amongst easily arranged
their patients, but there are other factors.
In a study of 400 GDPs in Manchester18 it Efficiency All referrals are appropriate and timely, primary care
was found that, not surprisingly, the antici- & Effectiveness mechanisms for filtering are foolproof
pated difficulty of the planned procedure
was the most common reason for referral. No inappropriate capture and retention of patients by
There was, however, a wide variation in secondary services, patients are referred back
referral rate between different practitioners; once specialist care is complete
29% said that a preference not to carry out
surgical procedures was a factor in making Routine care by PDC practitioner continues as
referrals and a similar proportion cited lack appropriate during lengthy courses of specialist care
of appropriate facilities or staff as a factor.
More surprisingly, those who had received
postgraduate training were not only found
to carry out more procedures in their own It has been suggested that distance from themselves exert an influence on decisions
practices but were also more likely to refer the specialist may be a factor,21 dentists to refer. In the study by Coulthard et. al.,18
patients, suggesting that practitioner educa- close to a specialist centre being more likely GDPs reported several factors influencing
tion may exert both positive and negative to refer. Whether this is entirely a practi- referral including: length of waiting list
influences on referral rates. tioner factor or one modified by patient fac- (57%), personal contact with a surgeon
A survey of dentists operating in a health tors is unclear. (56%) and the ease of access (52%). Thus,
maintenance plan referring to endodontic Lastly, and perhaps most obviously, the an NHS trust with waiting list problems
specialists in the USA19 found that older, development of advanced clinical skills which appoints an additional specialist
more experienced dentists were more likely within primary care may well be a factor in with associated support might find that any
to refer. Managed care organisations reducing referrals; a survey of oral surgery net reductions in the number of patients
(MCOs) in the USA have placed restrictions provision in England and Wales between waiting are less than the extra number of
upon referral to specialists, presumably as a 1984 and 199122 suggested that an increase patients seen and treated unless further
way to control costs, insisting that the gen- in oral surgery provision in the NHS Gen- mechanisms are brought to bear. A simple
eralist carry out treatment, particularly eral Dental Services might be linked to analogy would be what happens when
when periodontal treatment is proposed.20 improved skills and diagnostic equipment. attempts are made to solve traffic conges-
Whilst this is unlikely to be a factor with Practitioner factors reportedly associated tion by building new roads. This effect
new DBCs providing routine care in the UK, with referral are summarised in Table 1. might be magnified by the new specialist
the reverse might occur where dentists are undertaking purposive or accidental self-
encouraged to refer in certain circum- The role of the specialised service as a promotion to PDC practitioners, for
stances, either as a way of limiting the treat- factor in referral rates instance by giving postgraduate lectures.
ment provided by the dentist or as a form of It is apparent from a number of studies that The consequences of developing local
risk management. factors relating to the specialised services links and ‘being known’ are potentially

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great as seen in a study of implant referral available in PDC is available and accessible complexities of outpatient care. Soc Sci Med
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United Kingdom 1993 London: HMSO 1994.
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fewer problems in referring their patients where all referrals are appropriate and hap- caries experience of 14-year-old children in the
than those in locations at a considerable pen at the right time, patients are referred United Kingdom. Surveys coordinated by the
British Association for the Study of
distance. The situation is made worse if back to PDC once ‘specialised’ treatment is Community Dentistry in 1998/99. Community
treatment is likely to require multiple completed, they continue to see their PDC Dent Health 2000; 17: 48-53.
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15 Bradnock G, Waplington J. Commissioning
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problems have been cited as barriers to refer- their relative importance. In the next practitioners and the public. School of Dentistry.
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16 Department of Health. A conscious decision: a
factors might well be active in dentistry. It is some suggested solutions. review of the use of general anaesthesia and
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