Community Dent Oral Epidemiol 2012; 40: 247256 All rights reserved

2012 John Wiley & Sons A/S

Dental practitioner concepts of efciency related to the use of dental therapists

Harris RV, Sun N. Dental practitioner concepts of efciency related to the use of dental therapists. Community Dent Oral Epidemiol 2012. 2012 John Wiley & Sons A S Abstract Objectives: Efciency is concerned with producing maximum output with the minimum input, although what constitutes inputs and outputs within an organization is not always clear. Labour substitution is one method of achieving efciency gains, although cost savings are found to be context dependent and may not be achieved in some situations. Because dental therapists (DTs) in England are permitted to work in dental practices, we set out to investigate how efciency with respect to the use of DTs is conceptualized by practitioners to deepen our understanding of the potential for substitution to realize efciency gains in dental practice. Methods: Nine dental practices were selected using a purposive sampling methodology to give a range of practice size and DT employment arrangements. Semi-structured interviews were held with 26 dentists. Transcripts were coded and analysed thematically. Results: Efciency was perceived as optimum use of surgery time to generate intermediate outputs of (i) managing patient ow to give patient satisfaction and business cash ow and (ii) volume of work (procedures and numbers of patients). DT efciency gains were evaluated according to whether lower labour costs were offset by a slower working pace and higher rate of failed appointments. Patient need and demand, and whether the practice had health improvement goals, inuenced whether DTs were deemed to improve efciency. Conclusions: Findings are in accord with skill mix reviews in wider health care that substitution may be effective in improving efciency but this may be limited to particular situations where conditions are conducive. More studies are needed to explore these issues further in other dental practice contexts and with other groups of dental auxiliary.

Rebecca V. Harris and Ningwei Sun

Department of Health Services Research, University of Liverpool, Liverpool, UK

Key words: delegation; dental practice; dental therapist; efciency; nance Rebecca Harris, Department of Health Services Research, Institute of Psychology, Health and Society, Liverpool University School of Dentistry, Room 113, Block B, Waterhouse Building, Liverpool L69 3GL, UK, Tel.: +151 795 5334 e-mail: harrisrv@liverpool.ac.uk Submitted 4 April 2011; accepted 21 December 2011

Efciency is all about optimizing our use of resources. Technical efciency (sometimes called productive efciency) describes the relationship between resources or inputs (capital, materials and labour) and outputs (e.g. health outcomes) (1). It refers to the ratio of an index of output to an index of input, for example, output per labour hour. As there may be a number of inputs and outputs, as is the case in health care, technical efciency may be concerned with the ability to produce a maximum rate of output with a given combination of inputs (2). To achieve maximum efciency in terms of cost, it is necessary to choose the combination of
doi: 10.1111/j.1600-0528.2012.00670.x

inputs which produces the desired output at lowest cost (cost efciency). The cost of the inputs is therefore relevant, and a choice may need to be made, for example, as to whether to employ dentists or auxiliaries such as dental therapists (DTs). Cost efciency would depend not only on how much less DTs were paid than dentists, but also what their rate of output per hour was, relative to dentists. Academics studying organizational behaviour take a wider view of efciency. Although they view the concept of efciency as central to organizations, they recognize that at an organizational

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level what constitutes inputs and outputs is not always clear (3). The answer as to what should be counted as inputs and outputs, and thus what constitutes efciency, is not objective and neutral. The concept of efciency is therefore identied as a signier (recognizing that various people whether proponents or practitioners have their own model of what efciency signies). Jackson and Carter (3) therefore argue that the concept is open to analyse semiotically as well as scientically. There are several studies of efciency within the dental sector (49). Almost all have taken a policy perspective and are concerned with the system as a whole. A societal perspective takes into account the input costs of training personnel relative to their output in terms of man-labour years: a relevant consideration in the context of labour substitution, because dental auxiliaries are mainly women (10) and female dental practitioners who take a career break are anticipated to have a career 25% shorter than other dentists (11, 12). Previous studies of dental efciency (49) have mainly used economic approaches and concern a comparison of the efciency of different types of dental service using Data Envelopment Analysis (DEA), which involves analysing the relation between multiple inputs and outputs. Input factors examined in these studies include numbers of practitioners, material costs, man-labour years, total hours worked by dental practitioners and the operating cost of dental services. Output factors included are numbers of patient treated, numbers of dental visits, numbers of health education and prevention contacts and numbers of treatments. These output measures are all based on production goals and thus represent the fairly narrow perspective of technical efciency. Furthermore, output measures previously used are intermediate outcomes rather than health outcomes, which is not ideal (2). A focus on the technical efciency of dental services reects a scientic management approach that forms the basis of most manufacturing industrial work (13), emphasizing the fragmentation of work and entailing production systems based on time studies, conveyor belts and piece-rate working. This approach focuses on the distinction between means and ends, with the means regarded as purely technical and value-neutral (14). However, the delivery of dental care in dental practices is more complex than this. The value of the output needs to be taken into consideration, as do important human values such as social aspects of work, wages, the pace of work. The goal of the dental

practice will to some extent dene the value placed on the output. These goals may include both ofcial goals (reecting public acts and reporting) and operative goals (what the organization is actually trying to do). Furthermore, ofcial and operative goals may not necessarily coincide. For dental practitioners, operative goals include business goals as well as goals related to providing care as a health care professional (15). In the UK, as in other health systems, dental practitioners work as independent contractors of health care. They provide dental care either on a private basis or for the National Health Service (NHS), or both. Whilst dentists are reimbursed by the government (funded through central taxation) for NHS care, this payment (supplemented by patient charges) is calculated to meet all NHS-related practice expenses with any remaining being the practice prot. Dental practice owners are therefore responsible for their own staff employment, income, expenses, etc. Thus, principal dentists are both care providers and business owners. They have not only goals concerned with caring for their patients but also business goals concerned with expanding their businesses or maintaining the practice prot level, etc. As doctors (and dentists) are not naturally efcient (16), remuneration strategies by way of nancial incentives are recommended as a policy tool to increase efciency (17). In England, there has been a recent change to the dental remuneration system, from a fee-per-item (FFI) system to one based on targets of units dental activity (UDAs). The 400 dental items associated with the previous FFI schedule have been condensed into just three bands. Band 1 includes examination and prevention; Band 2 includes routine treatments, for example, llings, extractions; and Band 3 involves complex treatments, for example, crowns and dentures. Each band is associated with a certain number of UDAs that are awarded to practitioners for the procedures they nish within that band in one course of treatment; that is, one UDA is given for a Band 1 treatment, three UDAs for a Band 2, and 12 for a Band 3. An annual UDA target is allocated to each contractor (normally the principal dental practitioner) based on their historic performance and the price of per UDA which is set by the local NHS Primary Care Trust (PCT). Remuneration is by a block payment to the contractor, conditional on achieving the agreed UDA target. A number of perverse incentives have been recognized in this system (18), one of which is that

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delegation of work to DTs working in dental practices is discouraged (19, 20). Whilst a FFI system is geared towards achieving technical efciency, a recognized downside of the system is a tendency towards overtreatment especially where there is a low prevalence of disease. Although the English dental reforms were intended to reorientate the system away from an interventionist approach and towards more preventive care; the nature of the banding system means there are actually only weak incentives for practitioners to actively engage in providing preventive care. Banding of treatments has also dis-incentivized delegation because DTs contributions to team output are more difcult to assess (20). Although operating dental auxiliaries are being trained and function as an important manpower resource in many parts of the world, England is one of the few places in the world where DTs are permitted to work in dental practice (21). As labour costs are an important input consideration, the substitution of dentists for a cheaper alternative is suggested as one way in which efciency in dental care provision might be improved (2224). Increased delegation can improve technical efciency as seen in an American study using computer simulations to vary the number of dental chairs and optimize the use of space and human resources (24). However, other studies (6, 9, 25) show that cost efciency of dental services is not improved by shifting input allocation to dental auxiliary personnel. The cost-benets of using auxiliaries in dental practice appear to be rather more complex than results suggest from economic studies alone. Wang (6) reports that it would save dentists time but not money to extend the use of hygienists. However, if there were a shift in the type of procedures referred, the authors suggest the economic argument might swing in favour of hygienist employment. In a simulation experiment of the use of expanded function dental auxiliaries (EFDA) in a private dental practice, similar conclusions are drawn (25). The most efcient auxiliary conguration was found to only increase patient visits by 11% with an increase in net income of 3%, leaving dental practice owners wondering whether the 3% merited the additional management costs associated with delegation. However, comments from the two referring dentists in this study were more positive and emphasized that using EFDAs had enabled them to improve access to their patient pool and thus deliver more dental care whilst

maintaining quality standards aspects not captured by the economic analysis. For a fuller understanding of the issues that determine the optimum use of dental auxiliaries in dental practice, this study explores how efciency in relation to the use of DTs is conceptualized by English dental practitioners.

Methods
This study was part of a wider multiple-case study concerned with the employment of DTs in dental practices (26). Nine general dental practices were identied in the north of England using a purposive sampling methodology based on the selection parameters of the size of dental practice, whether a DT was employed, and the type of model of DT delegation and nancing within the team. Six of the practices employed at least one DT whilst the other three did not. Two of the three practices not using a DT had previously employed one, but had subsequently decided to terminate the DT employment. As a qualitative methodology was employed, selection of cases (dental practices) was on the basis of identifying both typical as well as negative cases to explore the concepts under investigation (27). Research ethics approval was obtained (08 H1012 9), as well as NHS Research and Development approval from each PCT relating to the dental practices involved in the study. Semi-structured interviews were conducted with a total number of 26 dentists in these practices. Twelve were principal dentists (practice owners) and 14 were associate dentists. All the principals in the nine practices were interviewed. Interviews (one, non-dentist interviewer) took place using a topic guide, which was rened as the study progressed to incorporate emerging themes. All interviews were audio taped and transcribed verbatim. Both deductive and inductive approaches to analysis were employed. At the outset, a framework of Inputs, Process and Outputs (the IPO model) was used, being an accepted model used widely in social research (28). A coding system was further developed as the interviews progressed, leading to identication of emerging themes and construction of a thematic framework. Particular attention was paid to analysis of sentences where dentists had used the words efciency and efcient. Data analysis was undertaken separately by the two authors to minimize interpretation bias, with consensus achieved by discussion.

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Results
Outputs were categorized as (a) main outputs and (b) intermediate outputs. The main outputs identied were (i) income, (ii) patient satisfaction and (iii) health improvement of patients. Intermediate outcomes were (i) managing patient ow to give patient satisfaction and generate turnover to ensure cash ow for the business and (ii) production involving completing a required volume of work (in terms of numbers of procedures and numbers of patients) to achieve activity targets (Fig. 1). Inputs were understood as business overheads which were xed (cost of the building and surgery running costs, cost of dental materials, dental nurse assistance and laboratory work necessary to complete the work, marketing and administration). Inputs that were more variable were labour costs: the costs of a DT, dentist or hygienist.

Efciency as optimizing the use of surgery time

Efciency was understood as the capacity of the main resource (time in the surgery) to maximize both intermediate and main outputs (Fig. 1). The reason the practice is viable is because were using it full time. Its basically trying to make it run as efciently as possible when theres no spare capacity. Practice F, principal dentist 2 Because the use of surgery time was of central importance, the outputs produced by dentists and DTs within a certain time were a main way in which the relative efciency of dentists and DTs was compared. At the end of the day the best measure of that is the amount of time they take to do a full scale and polishIf

they [DT] are taking a similar amount of time as a dentist, but, you know, were paying them half as much to do it, has to make sense business wise. Everything else is the same. Practice F, principal dentist 1 Dental therapist outputs in a given surgery time were sometimes viewed as being less than that of dentists, compromising the efciency of the practice. The surgery time that they use up...you do think well, if I had got a dentist in that surgery time shed use it up more efciently than what theyre doing. Practice E, principal dentist There were several reasons for this. DTs sometimes worked at a slower pace than dentists in the practice. There were also some reports of a higher failed appointment rate with DTs than with dentists; the consequence of which was exacerbated because DT booked appointments were further apart. We eventually got her (DT) down to 20 minutes for a scale, well most dentists would probably have 10 minutes for a scale & polish so for 10 minute failure for a dentist, ok you can cope with [that] but all she (the DT) needs is 2 failures and shes be sitting around for an hour... so her failures were worse. Practice A, principal dentist 2 Based on the work that theyre getting through in terms of the times they take over the work thats been sent to them then I would say yes it works. The fact that would compromise that is their FTA [Failed to attend] rate. Practice F, principal dentist 1 As well as a slower rate of working, because DTs were restricted to undertaking certain tasks (regulations prohibit DTs from undertaking examinations and treatment plans), DTs were at a

Input
Fixed Building Surgery overhead Cost of dental nurse Dental materials Laboratory costs Marketing Administration

Process Surgery time

Intermediate output
Waiting list/ waiting time Cash flow

Output

Patient satisfaction

Patient flow Rate of working Failed appointments Volume of work (number of patients and procedures) Income

Variable Labour costs (dentist/DT/hygienist) Needs of patient population Patient demand

Health improvement

Activity targets

Fig. 1. Dental practice input, process and output factors identied by practitioners.

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disadvantage when outputs in terms of obtaining UDAs were compared with dentists. DTs cant generate the UDAs like dentists can, you know. Theyre no good for the check-ups, you know cause dentists can see forty checkups a day, cant they? You know Im not saying its easy or its the right thing to do because the but anyway, dentists can see forty patients. Forty checks plus forty UDAs. The therapist has no way for forty UDAs. Its impossible. Practice E, principal dentist A dentist will do a greater volume of work and hit the UDA targets a lot more quickly than a therapist will do. Practice A, principal dentist 1

Perceived determinants of using DTs in an efcient way

Practices varied in whether they viewed DTs as contributing to practice efciency. Of the eight practices employing a DT, four had an overall view that they positively contributed to practice efciency and four held a generally negative view (Table 1). It is notable that all four of the practices with a positive view identied that goals for the practice included wider aspects than purely generating business prot. In response to an open question about practice goals, these practices mentioned service quality as well as production as a priority, and DTs were seen as particularly important in realizing wider oral health goals. I can give them the llings to do so it gives me more time and actually its because theyre doing a lot more oral health work, the oral health has improved dramatically. Practice D, principal dentist Practitioners also identied a number of scenarios that might determine the efcient use of DTs. The rst related to the type of needs of patients (Fig. 1). If patients required extensive restorative work, some practitioners felt it was more efcient for the care to be undertaken by a dentist rather than a DT. This was because dentists were more likely to undertake several restorations in the same quadrant at the same visit. This is what Im talking about when I say kind of patient selection. The therapist is great for turning a course of treatment from one UDA to three UDAs if that can be achieved within half an hour or so. So where youve got patients that needs one or two llings, um, and some perio work, so a clean-up, those are the patients that they need to see. Somebody who needs quadro-dentistry, the therapist would actually take a hell of a lot longer than I would to get that done and so for those patients it makes more sense for me to see them. Practice C, principal dentist In some situations where treatment complications were possible, this could lead to a referral back to the dentist with the result that multiple patient visits might be required thus compromising patient ow as well as patient satisfaction. Practices located in areas where patients presented with multiple and extensive cavities were therefore perceived less suited to using DTs efciently by some practitioners. It becomes inefcient if you send a patient to a therapist for a lling and that lling turns into an exposure and that patient needs an extraction and a root

Efciency as maximizing patient ow

Maximizing the volume of work completed in a given surgery time period and translating this into income by attaining UDAs was not the only aspect of how efciency was viewed. There was also an importance placed on completing the required courses of treatment of patients as quickly as possible. There were two reasons for this: to give a good service for patients (who often were repeat customers of the practice) and to speed cash ow through the practice as a business (Fig. 1). I dont think its efcient to make people wait 810 weeks. It doesnt help with the cash ow of the business. Practice A, principal dentist 1 Because theres so many patients and theres so much turnover here, um, its useful very very useful. Because patients can see therapists more quickly than I have a free appointment, so the patients are happy because theyre nished and seen quicker than waiting for me to have a free appointment to see them. Practice E, associate dentist The need to maximize the speed at which patients were processed through the practice also meant that sometimes treatment was better undertaken by a dentist rather than by referral to a DT, which would mean additional trips to the practice. Under some circumstances its actually quicker for an associate to do it- so if you have somebody that comes in for an exam, who needs a lling and a clean-up say, while you wait for the local to work, you doing the cleanup, youre doing some OHI and preventive stuff and then once the locals worked you can go ahead and get the lling done. Now the amount of time that would take would be a lot less and probably more convenient to the patient because theyll get everything done in the one visit rather than doing an exam, coming back and getting treatment done by a therapist. Practice C, principal dentist

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Table 1. Practice goals, inputs, process and output factors identied for the nine practices studied, with overall judgement on whether a dental therapist contributes to efciency Inputs Staff costs (dentist DT) Overheads (cost of set up surgery, surgery time cost and nurse) Failure rate Overheads (material cost) Time (dentist clinical time) Staff cost (DT wage) Failure rate Rate of working Process Outputs DT inuence on efciency Negative

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Negative Staff cost (DT wage) Time (dentist clinical time) Overhead cost (surgery time cost) Time (dentist DT clinical time) Staff cost (DT wage) Overheads (surgery time cost) Time (dentist clinical time) Staff cost (DT wage) Overheads (surgery time cost, nurse) Time (DT clinical time) Failure rate Rate of DT working Failure rate Rate of DT working No DT Failure rate Production (no. of UDAs, no. of patients treated) Prot Cash ow Quality of care (patient satisfaction) Production (no. of patients treated, no. of UDAs) Quality of care (DT working quality, patient satisfaction) Prot (UDA income, private income) Production (no. of UDAs) Quality of care (DT working quality, patient satisfaction) Positive Positive Negative Final health outcomes (oral health improvement) Production (no. of procedures) Quality of care (DT working quality, patient satisfaction) Production (no. of patients treated, no. of UDAs) Quality of care (DT working quality, patient satisfaction) Prot (UDA income) Prot Quality of care (DT working quality, patient satisfaction) Production (no. of patients treated) Positive NA Negative Positive Staff cost (DT wage) Overheads (surgery time cost) Time (dentist clinical time) Overheads (surgery time cost) Time (DT clinical time) Prot Production (no. of UDAs) Production (no. of procedures) Prot Quality of care (DT working quality, patient satisfaction) Production (no. of patients treated)

Practice

Practice goals

Business goals: grow branch practices; expand private work

Business goals: maintain income level and look towards private sector to grow

Business goals: potentially grow the business; cut costs Health goals: quality dental care for the whole family Business goals: hit the target; maintain the income at the present level Health goals: improve oral health

Business goals: meet target; maintain income level; expand practice if the PCT allows

Business goals: bottom line stay the same; achieve target; Health goals: offer a comprehensive quality service to everyone who want to come here Business goals: grow business

Business goals: maintain the income at present level Business goals: expand and grow the business Health goals: meet the needs of the local population through work with the PCT

DT, dental therapist; PCT, Primary Care Trust; UDA, units dental activity.

Dental practitioner concepts of Efciency

canal treatment and get referred back thats when it starts getting inefcient so you, the, so the answer is that dont refer that kind of lling it thats whats going to happen. Practice F, principal dentist 1 On the other hand, where practices were located in areas where there was an overwhelming demand, DTs were deemed to be an effective way of managing such demand (Fig. 1). Patients can see therapists more quickly than I have a free appointment, so the patients are happy because theyre nished. Practice E, associate dentist

Discussion
The World Health Report 2000 (29) notes that determining and achieving the right mix of health personnel are major challenges for most health care organizations and health systems. Oral health care systems are not immune to this challenge (30). Whilst the focus of the study concerns DTs in dental practices in England, it raises issues that are also pertinent to the use of other types of auxiliary personnel in dental practices such as hygienists a group working more widely in dental practice particularly in the USA, Canada and Japan (21). Our study describes how dental practice efciency is viewed by practitioners and identies some of the factors in dental practice that determine whether substitution of auxiliaries for dentists is deemed effective in this setting. Before discussing the results in more detail, it is worth noting that the perspectives reported were gathered from a relatively small group of participants, although the size of the sample is adequate given the use of qualitative methods (27). Qualitative methods allow an in-depth analysis of phenomena, often for the purpose of generating theory, and as such are not usually judged by measures of scientic quality such as reliability or generalizability (31). However, it should be noted that the sample may not be representative of English dentists, of English dental teams or of the use of auxiliaries in dental teams in other countries. It does though provide some insight that complements previous studies of efciency using quantitative methods. There are only other two studies in the literature (32, 33), which report determinants of dental practice efciency without using economic methods, although in both the boundaries of the concept are not clearly outlined. This study provides a framework outlining how the concept is considered in English dental prac-

tices, which can be tested and rened with further work in other settings. The Nufeld Report (22) states that In terms of cost-effectiveness, it makes little sense for dentists to spend much of their time carrying out work that could be done effectively by someone trained for a shorter period to do a narrower range of relatively simple work at less cost, and thus concluded that a more effective oral health service could be provided within the cash limits envisaged by the government if suitably qualied auxiliaries were used in greater numbers. This approach underpins some of the policy decisions regarding dental manpower in the UK, but bears further examination. Substitution is an aspect of skill mix policy that describes a transfer of tasks from highly qualied, expensive professionals to less highly qualied, cheaper professionals with the intention of reducing costs and increasing efciency (34). Reviews of the literature, mostly in the context of nurse doctor substitution, suggest that these gains are rarely achieved (3537). In most studies, savings on nurses salaries are offset by lower productivity (longer consultations, greater recall rates) and are often context specic: achieved in some situations and not others (35). Another issue is that doctors often continue to provide the same service as nurses, leading to duplication rather than substitution of care (38). To realize efciency gains, active steps are recommended to ensure that doctors discontinue work delegated to nurses (39). In the UK, 90% of primary care dentists work in dental practices (40), and therefore understanding the dental practice context is key to realizing the potential of any efciency gains in the substitution of DT for dentists in the workforce. This study identies efciency as a concept that is rooted for practitioners in the use of surgery time, with more than one output consideration. Practitioners studied were concerned not only to generate as much volume of care and thus income as possible, but also to process patients quickly to manage cash ow and patient demand. Some, but not all, also had health improvement goals. Within this context, the type of patient care was relevant to whether a referral to DTs was deemed efcient. Patients with high levels of disease (many restorations) were thought less suitable for referral because dentists would undertake care in fewer visits and there was a risk of complications necessitating referral back to a dentist.

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Perceptions of the DTs contribution to the dental team reach to the heart of exploring the nature of dental practices as organizations. UK dental practices operate on a cost-volume-prot business model where contributions to team output are evaluated as a group of individuals (20). Whilst it may be true that delegation to DTs enables practitioners to be free to undertake more complex and highly remunerated work, this is relatively infrequently taken into consideration when practitioners evaluate the contribution made by DTs. One of the challenges in introducing labour substitution to dental teams is that for optimum efciency, there needs to be a clear demarcation of tasks, without any overlap of procedures undertaken by dentists and auxiliaries. In the English system, only dentists are allowed to undertake diagnosis and form treatment plans, unlike New Zealand, where a referral upwards model is used. This means that the only type of specic tasks that could be allocated to DTs as opposed to dentists would be simple restorative and preventive care. However, as illustrated in this study, there are often circumstances in the dental practice where dentists retain this type of care, either to prevent inconvenience to the patient or to maximize patient ow through the practice. This then weakens the argument for efciency gains in dental practice using substitution of dentists. Nevertheless, there may be dental practice situations (high patient demand, relatively low levels of disease) where DTs are more likely to be considered to increase efciency. This particularly applies to situations where there is a choice of workforce and sufcient numbers of dentists available to do the work. In high dental need areas that are under-dentisted, DTs may be a necessary and useful part of the workforce (41). This bears out conclusions from other studies that substitution has the potential to increase efciency, but this is situation specic (29). The nding that patient ow is relevant to assessing efciency relating to the use of DTs reects some of the principles underpinning earlier computer simulation studies concerning the use of EFDAs (42, 43). The ow of appropriate patients to auxiliaries is critical to whether they are judged to be a cost-effective means of supplying services. There is an inbuilt assumption in these models that sequencing of patients is optimal, utilizing personnel to the maximum (42). However, real-life limitations exist in dental practices where the needs and convenience of the patient population must be balanced against the needs and motivations of

dental practitioners (43). Within computer-generated models, there is no attempt to assign a cost to patient waiting time, rather the information is then presented to allow the decision maker (whether the practice owner or national health planner) to make a judgement against the maximum performance statistics generated, as to how much these statistics should be mollied to take into account potential conicts with the interests of patients. Compromises may need to be made, which dilute the potential of the dental practice to perform at maximal efciency. Several operational research studies show that in industries such as dentistry, task scheduling is critical to maximizing efciency. Hence, more sophisticated scheduling in dental practices may well increase efciency where substitution is used and is an area of dental education and research where development is needed. Computer simulations also assume that task times do not vary with output. However, as output expands, labour inputs may well interact at chairside in response to increased demand (42). In other words, because dentistry is a human service industry, providers may respond to the pressure of patients waiting. Dentists may have a higher demand for their services than do DTs, and this may in some part explain why practitioners consistently reported in the study that the work rate of DTs was below that of a dentist. Another explanation is that the DTs were relatively less experienced than dentists clinically an aspect not explored in the study. On the other hand, a comparison between dental undergraduate teaching and that of DTs shows that the clinical training measured in terms of number of operative hours (phantom head) and potential patient treatment hours are remarkably similar in both groups (44). Given that restorative teaching for DTs is restricted to certain areas of restorative work, it is therefore likely that compared with newly qualied dental students, DTs are relatively highly skilled for the tasks they are allowed to undertake. Nevertheless, the reason that dental auxiliaries have a relatively low output compared to dentists needs to be explored in future studies. Were this aspect of production to be addressed, the efciency of using auxiliaries within the dental team is likely to be improved. In conclusion, the dental practice context appears to reect what is found in the wider health care context that from a managerial point of view it is very easy to determine what a cheap skill mix is in terms of labour costs. It is much more complicated and difcult to come up with the ideal or best skill

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mix (35). There needs to be a greater recognition that dental teams are relatively complex organizations and goals may vary. More research is needed to complement existing economic studies.

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