Evaluation of Postgraduate Foundation Training for Dental Therapists: 
Does participation enhance career prospects?

doi:10.21203/rs.3.rs-3655926/v1

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Evaluation of Postgraduate Foundation Training for Dental Therapists: Does participation enhance career prospects?

https://doi.org/10.21203/rs.3.rs-3655926/v1

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OBJECTIVES: This study explored the value of dental therapy foundation training (DTFT) in the UK and how participation influenced career prospects.

METHODS: The study used a survey incorporating open, closed, Likert scale and multiple-choice questions. Quantitative data were analysed with IBM SPSS Statistics v26. Analysis of qualitative data was undertaken by two researchers. Final themes and subthemes were confirmed following round table discussions.

RESULTS: 94 survey responses, 61 from DTs who had not undertaken DTFT (Group A) and 33 who had undertaken DTFT (Group B). Most respondents were female (95%) with a mean age of 33.8 and 32.9 years respectively. 58.3% of Group A respondents did not believe that completing DTFT would have enhanced their career prospects, whereas 63.6% of Group B said that they gained a position as a result of completing DTFT. Participation in DTFT increased perceived clinical confidence in Group B and 81.8% were likely to recommend DTFT to their peers. A total of 13 major themes and 12 subthemes were identified.

CONCLUSIONS: DTFT schemes were considered a valuable educational experience which increased clinical confidence. Participation may have enhanced career prospects. Barriers were encountered by DTs when seeking work, regardless of participation in DTFT.

Health sciences/Health care/Dentistry/Dental education/Dental foundation training

Health sciences/Health care/Dentistry/History of dentistry

Dental therapists (DT) have been an established mid-level provider and member of the dental team for many years in the United Kingdom (UK) since their establishment in 1909.⁽¹⁾ The DT role has evolved with several pivotal developments in recent years which have impacted on how this dental care professional (DCP) group can practice. Before 2002, DTs in the UK were only permitted to work in community practices.⁽²⁾ In 2013 the General Dental Council (GDC) published the Scope of Practice (SOP) for DTs and permitted DTs, dental hygienists and dual-qualified dental hygienists and dental therapists to practise under direct access, negating the requirement for referral from a dentist.^{(3, 4)}

National Health Service England (NHSE), formerly Health Education England (HEE), is responsible for the training of an appropriate health workforce, which should have the correct balance of numbers, skills and behaviours to optimise exceptional healthcare.⁽⁵⁾ To support skills consolidation and progression, postgraduate dental therapist foundation training (DTFT) schemes (previously known as vocational training [VT]) for DTs were operating for 14 years.⁽⁶⁾ The longest established scheme and originator of DTFT is NHSE Thames Valley and Wessex which was first reported on in 2009 and subsequently in 2011.^{(6, 7)} The provision of DTFT schemes has been variable.⁽⁵⁾ However, the more recently published ‘Advancing Dental Care’ report stated that in order to support a multi-professional oral heath workforce, a standardised, national DTFT scheme should be developed.⁽⁸⁾ An online search established that the following schemes were operational from 2021–2023 (Table 1).

Table 1

Current and future DTFT schemes and Deaneries.
	Scheme and Deanery	Website / information
1	NHS Education for Scotland	https://www.nes.scot.nhs.uk/media/fxocsrly/final-nes-tvt-guide.pdf
2	Health Education and Improvement Wales	https://heiw.nhs.wales/education-and-training/dental/training-programmes/welsh-dental-therapy-foundation-training-programme-wdtft/
3	Health Education East of England	https://heeoe.hee.nhs.uk/node/7896
4	Health Education England London	https://london.hee.nhs.uk/dental/dental-foundation-therapy
5	Health Education Midlands and East	https://heeoe.hee.nhs.uk/dental/dental-therapist-foundation-training
6	North East and North Cumbria Deanery	https://madeinheene.hee.nhs.uk/dental_training/Dental-Therapists
7	North West Deanery	https://www.nwpgmd.nhs.uk/dental-therapist-foundation-training-scheme
8	HEE South West Deanery	https://dental.southwest.hee.nhs.uk/about-us/dental-foundation-therapist-programme/
9	Thames Valley and Wessex Deanery (Oxford)	https://thamesvalley.hee.nhs.uk/dental-directorate-thames-valley-and-wessex/therapist-training/
10	Yorkshire and Humber Deanery	https://yorksandhumberdeanery.nhs.uk/dentistry/programme/dental_therapy_foundation_training
Table 1: DTFT schemes active in academic year 2022–2023 or anticipated 2023–2024.

Oral and dental diseases continue to affect a significant majority of the population despite improvements over the past decade and it has been reported that disease levels vary between population groups which is indicative of continuing health inequality.⁽⁹⁾ It has been reported that the National Health Service (NHS) is providing access to fair and efficient services.⁽¹⁰⁾ However, there are inconsistencies in NHS dental service provision whereby approximately half of the population does not attend regularly and patients with increased need experience more difficulty accessing NHS dental services.⁽¹¹⁾ Optimising the potential of the entire dental workforce is therefore an imperative.⁽¹²⁾ Dentists do not work in isolation and are supported by a multidisciplinary, mixed-skill team which is expanding with the increasing numbers of mid-level DCPs.^{(13, 14)} There are currently 116,772 GDC registrants (July 2022)⁽¹⁵⁾ (Fig. 1).

Access, prevention and high-quality provision are essential to achieve good oral-health, with the whole dental team working towards a common oral-health goal.⁽¹²⁾ A strategy to meet the healthcare requirements of the population when commissioning and providing future models of NHS dental services is essential.⁽⁵⁾ Therefore, investigation into how training can optimise skill-mix, particularly the skills of DTs, is appropriate. As a result of the work completed as part of Advancing Dental Care, a clear “blueprint for change” has been devised to develop a future dental education and training infrastructure. The reform emphasised a multi-skilled professional workforce with the skills and competencies to support and meet the oral-health needs of patients and communities.⁽⁸⁾

As evidenced, there has been progression in the provision of training opportunities and professional development of the role of the DT, with promises of education reforms and changes to career pathways for all DCPs and dentists.^{(5, 8)} There has been much emphasis placed on the whole team approach to dental care provision and the importance of the DT in this vision.^{(5, 8, 16, 17)} Many mid-level, prevention focussed DTs have been highly trained at the expense of the UK-taxpayer.⁽¹⁾ Despite this, DTs widely report barriers and face adversity and challenges in securing roles which permit them to perform their full SOP.^{(2, 18–20)} These professional barriers have consequences for DTs such as under-utilisation of SOP, reduction in clinical skills (deskilling), lack of job satisfaction, career frustration and uncertainty and lack of confidence.^{(2, 18–22)}

To further compound the existing barriers faced by DTs, the recent SARS-CoV-2 virus which caused the Covid-19 pandemic, has also had immediate and longer lasting effects on the dental profession and provision of care. Dentistry is one of the most exposed and high-risk professions and Covid-19 is an occupational hazard for dentists and DCPs.^{(23, 24)} The pandemic has put a great strain on an already stretched dental service. From 28th March to 8th June 2020, routine dental care was completely suspended in the UK, with a focus on emergency and urgent care only.^(24–26) Despite the easing of restrictions, some barriers remained for the provision of dental care due to new infection control measures.^{(23, 27)} This lack of provision of care and consequential reduced access for patients has resulted in an over-stretched, over-whelmed service, with a back-log of treatment need and an increase in demand for dental appointments.^{(24, 25)} This has had a detrimental effect on the dental team with an intensification in work demands and an increased psychological toll and physical burden.⁽²³⁾

The aim of this study was therefore to examine the efficacy of postgraduate foundation training for DTs and evaluate whether participation increased clinical confidence, to investigate whether participation in the scheme enhanced career prospects and to determine barriers encountered by DTs in securing suitable positions, inclusive of Covid-19 restrictions.

The research was granted ethical approval from the University of Portsmouth Science and Health Faculty Ethics Committee (reference: SHFEC 2020-x64). A confidential pilot online survey designed using Google Forms was sent during August 2020 to nine DTs across the UK who completed DTFT. A series of questions were sent to respondents (100% response rate) to retrieve feedback on the survey design, usability and content; amendments were made according to respondent feedback.

The research survey was distributed through an email link via the British Association of Dental Therapists (BADT) on two occasions. The survey link was also posted via a closed social media group specifically for dental hygienists and dental therapists on seven occasions at approximately one-week intervals and responses were collected (October 2021 - January 2022). Participant information was included as part of the survey detailing ethical approval, UK General Data Protection Regulation (GDPR), how the data would be used, and a consent option.

The survey incorporated both open and closed questions, Likert Scale and multiple-choice questions. Questions were arranged using a ‘funnelling’ approach, with questions worded to prompt meaningful responses, and any complex questions broken down into a series of shorter questions. The survey was split into two ‘arms’ based on whether the respondent had undertaken DTFT or not. Section 1 collected participants’ demographic information, training and working practices. Section 2 explored why the participant chose to undertake DTFT or chose not to. The third section examined barriers participants have faced when seeking positions as a DT. An additional fourth section for the DTFT cohort examined the value of postgraduate foundation training. The findings of these individual sections will be reported separately.

Quantitative demographic data from the survey were analysed using descriptive statistics via spreadsheets and IBM SPSS Statistics version 26 software. Quantitative data eliciting participants’ agreement with statements or measuring beliefs were also analysed using IBM SPSS Statistics version 26 software. Chi Squared tests were used to statistically assess the differences between the non-DTFT and DTFT groups, a significance level of p < .05 was set. The qualitative data were thematically analysed by two researchers independently. Conceptualisation of themes was undertaken, with further “round-table” discussions to confirm themes and subthemes and minimise researcher bias. All researchers recognised reflexivity with LEGCK as the principal researcher who is also a DT who has undertaken DTFT, DRR an experienced researcher in qualitative dental research, a dentist and teacher of DTs, CMV a dentist, experienced researcher and teacher of DTs, and CL as head of a DCP training establishment, an experienced researcher, dentist and teacher of DTs.⁽²⁸⁾

Demographic and working practices

A total of 94 questionnaires were returned, 61 (64.9%) DTs who have not undertaken DTFT (Group A) and 33 (35.1%) DTs who have undertaken DTFT (Group B). The demographic and working practice findings of the respondents are presented in Table 2. There was little variance between the two groups in terms of gender and age, the majority of respondents were women (Group A 93.44%, n = 57; Group B 93.94%, n = 31), with a mean age of 33.8 and 32.9 years respectively. Levels of qualification and attendance at training institutes were similar between the two groups with most holding a Bachelor’s degree (Group A 49.2%, n = 30; Group B 51.5%, n = 17). The most common training institutes were the University of Portsmouth and the University of Birmingham. Of Group B, the majority of respondents (n = 12, 37.50%) undertook their DTFT scheme with NHSE Thames Valley and Wessex, Health Education and Improvement Wales (n = 6, 18.75%) and NHSE West Midlands (n = 4, 12.50%) were also well represented.

Table 2

Demographic, training and working practices of DTs.
Demographic	Group A Frequency (n)		Group A Percentage (%)	Group B Frequency (n)	Group B Percentage (%)
Sex
Female	57		93.4	31	93.9
Male	4		6.6	2	6.1
Non-binary	0		0	0	0
Prefer not to say	0		0	0	0
Age (years)
19–24	8		13.1	3	9.1
25–34	28		45.9	19	57.7
35–44	20		32.8	8	24.2
45–54	4		6.6	1	3.0
55–64	0		0	2	6.0
Undisclosed	1		1.6	0	0
Qualification (type)
Bachelor of Science (Dental Hygiene and Dental Therapy)	30		49.2	17	51.5
Bachelor of Science (Oral Health Sciences)	9		14.8	5	15.2
Diploma in Dental Hygiene and Dental Therapy	21		34.4	11	33.3
Diploma in Orthodontic Therapy	1		1.6	0	0
DTFT Deanery
Education for Scotland		-	-	2	6.06
Health Education & Improvement Wales		-	-	6	18.18
Health Education South East (KSS)		-	-	3	9.09
Health Education Midlands and East		-	-	1	3.03
North West Deanery		-	-	2	6.06
Thames Valley & Wessex Deanery		-	-	12	36.37
West Midlands Deanery		-	-	4	12.12
Yorkshire & Humber Deanery		-	-	2	6.06
Undisclosed		-	-	1	3.03
Training Institute
University of Portsmouth	10		16.4	5	15.2
University of Birmingham	6		9.8	4	12.2
King’s College London	5		8.3	1	3.0
University of Leeds	5		8.3	5	15.2
Teesside University	3		4.9	2	6.1
Other	19		31.0	10	30.1
Undisclosed	13		21.3	6	18.2
Main Work Setting
General Dental Practice (Mixed)	27		44.3	13	39.3
Private General Practice	26		42.5	7	21.3
NHS General Practice	2		3.3	3	9.1
Hospital Dental Services	2		3.3	1	3.0
Community Dental Services	2		3.3	6	18.2
Other	2		3.3	3	9.1
Working Commitment
Full-Time	37		60.7	18	54.5
Part-Time	23		37.7	14	42.4
Career Break	1		1.6	1	3.0
Main Patient Group
Adults	36		59.0	9	28.1
Children	1		1.6	0	0
Mixture of Both	24		39.3	23	71.9
Main Working Distribution
Periodontal Treatment	32		52.5	14	43.8
Restorative Treatment	2		3.3	5	15.6
Mixture of Both	27		44.3	13	40.6
Table 2: There was a range of demographic detail, training, and working practices across both groups.

Across both groups, mixed general practice (NHS and private) was the most common workplace (Group A 42.6%; Group B 54.4%). The majority of Group A stated that their patient demographic was predominantly adults (59.0%), whilst the majority of Group B stated both adults and children (71.9%). Of Group A most respondents indicated that the distribution of their working practice was mainly periodontal treatment (52.2%) or a mixture of both (44.3%) rather than just restorative treatment (3.3%). Group B respondents indicated that the distribution of their working practice was similar, periodontal treatment (43.8%) and a mixture of both (40.6%), however, they undertook more restorative treatment (15.6%).

Survey themes

Four of the questions elicited qualitative data via freehand answers. Analysis of these data identified 12 major themes in the four topic areas. Within the major themes, 13 subthemes were identified that described practice for DTs (Fig. 2).

The choice to undertake DTFT

Participants from both groups were asked concerning their rationale to either undertake DTFT or not. The main reason for not pursuing a place in a DTFT scheme was “there wasn’t a scheme geographically close to me” (40.0%), followed by “I didn’t want to” (23.3%) and “the salary wasn’t enough” (23.3%), others stated that they didn’t know it was an option (8.3%), or they applied but did not succeed in gaining a position (16.6%). Respondents described this decision in more detail in freehand answers and stated how the salary was not attractive enough to justify further training, how they felt extra training was unnecessary due to a lack of jobs in dental therapy, how their confidence levels were sufficient to start independent practice, and how they were limited by the location of the schemes.

Theme one: The DTFT Scheme was unnecessary

“Therapy jobs in short supply. More hygiene jobs and better pay.”
“I was offered a well-paid job without it.”
“The job I was starting out with offered a very supportive, open-door policy – with tutorials etc.”
“When calculated as an hourly rate it wasn’t appealing compared to going into practice.”

Theme two: Confidence levels

“I felt confident in my own abilities, I didn’t need a VT year. Some practice principals see a VT therapist as cheap labour for 12 months. Go and earn what you’re worth elsewhere.”
“I felt confident to get started in practice without further training.”

Theme three: Availability of DTFT schemes

“I graduated in November rather than June when the scheme runs from.”
“There wasn’t a placement near my hometown, as well as the practice I previously nursed at offered me a job on significantly more than a VT scheme.”
“The south west scheme practices were not released until you had a successful interview so I didn’t want to waste time applying if there were no practices close to me.”

Group B respondents were similarly asked about their decision to undertake DTFT training, and to rank the three options of most importance to them. These were “to increase clinical confidence” (93.9%), “for a supportive working environment” (90.9%), and “to help with the transition from education to independent practice” (90.9%).

Evaluation of the DTFT scheme

Respondents answered questions using an agreement scale (range: 1 = strongly disagree, 5 = strongly agree) concerning specific experiences and learning opportunities within a DTFT programme.^{(6, 7)} The responses highlighted that although respondents from Group B found the DTFT experience beneficial, there were short-comings in the schemes with improvements suggested.

Overall, 24 (72.8%) out of 33 respondents agreed that the study days were well matched to their learning needs, highlighting the importance of the study day curriculum. Twenty-nine (87.9%) agreed that they were personally well integrated and accepted in the foundation training practice. Twenty-seven respondents (60.6%) agreed that their trainer (educational supervisor) provided good support. The learning portfolios were reported to be a useful tracking and reflective tool for 23 (69.7%) respondents, although five (15.1%) disagreed. Twenty-two (66.6%) respondents agreed that completing DTFT had benefitted them in being able to integrate into mixed-skill dental teams (Table 3).

Table 3

Key results of evaluation of DTFT schemes.
Statement	Strongly disagree					Mean	Standard Deviation
	1	2	3	4	5
1. The study days were well matched to my learning needs.	1	1	7	12	12	4.00	1.000
2. I felt that I was well integrated and accepted in practice during my foundation training.	0	1	3	4	23	4.58	.792
3. My trainer provided good support whilst I was in training.	0	3	3	7	20	4.33	.990
4. The learning portfolios helped me to track and reflect on my progress.	1	4	5	13	10	3.82	1.103
5. As a result of completing foundation training, I have benefited by being able to integrate more into mixed-skill dental teams.	1	0	10	8	14	4.03	1.015
Table 3: Those who completed DTFT reported a positive learning experience.

Overall, those who completed DTFT reported a very positive experience. However, 69.7% (n = 23) stated that they would make changes to the DTFT scheme. Further freehand responses were analysed into three major themes; firstly, a positive stance, secondly a negative stance with the subthemes (i) a lack of support and (ii) more training for educational supervisors (trainers), and (iii) a theme focussed on study days.

Theme four: Positive stance

“I found the scheme very helpful in my transition to working in practice and if I hadn’t had the support from that practice, I would probably have stopped doing therapy due to a bad experience at another practice.”
“I don’t think I would be as competent without.”
“It did help me secure a therapy position in the south east.”

Theme five: Negative stance

i. Lack of support:

“I felt a lack of support from the organised (sic) ITP (Introduction to practice) especially when having problems … I also didn’t feel that the other dentists were willing to give advice when my trainer was on leave.”
“More practices available on the scheme, trainers to be more supportive especially with their time outside of clinic, better methods of feedback and support when things aren’t working well. Better financial remuneration.

ii. More training for educational supervisors (trainers):

“The practices that participate in this scheme need more training and regulation, as the support and working environment varied significantly from one practice to another. I was lucky to be in a supportive practice. Other therapists reported being treated like cash cows.”
“More training for the practices involved to understand the scope of a therapist, more training for the TPD (Training Programme Director) on what a therapist does and how to integrate them into the learning environment.”

Theme six: Study days

“I felt the study days were more advanced than my level of skill at the time, particularly restorative study days and clinical photography considering we were all working in NHS practices.”
“More hands-on therapy learning days!”
“Some study days were more toward things that therapists can’t do as not in our scope of practice.”

The impact of DTFT

DTFT and professional perceptions

Respondents from Group A were asked if they thought that completing a DTFT programme would have enhanced their career prospects; 58.3% (n = 35) answered ‘no’. Group B respondents were asked if they had gained a position as a DT as a result of completing DTFT; 63.6% (n = 21) answered ‘yes’; with 60.0% (n = 15) stating that this position was in a different workplace to their DTFT practice. Group A were also asked if they thought their lack of DTFT experience had influenced their current employer and 50.8% (n = 31) stated ‘did not seem to matter’, whereas 45.9% (n = 28) selected ‘no’. Similarly, Group B were asked if they thought their DTFT experience influenced their current employer and 40.6% (n = 13) stated ‘did not seem to matter’, and 18.8% (n = 6) said ‘no’.

Both groups were asked about the reaction of other DCPs and dentist colleagues toward their lack of DTFT or DTFT experience respectively. The majority of Group A (88.3%, n = 53) and Group B (51.5%, n = 17) selected ‘neutral’. However, six (10.0%) of Group A said the reactions were positive and only one (1.7%) had received a negative reaction, compared to 15 (45.5%) of Group B experiencing positive reactions and one (3.03%) having a negative reaction.

Confidence levels

To assess the impact of DTFT on clinical confidence, the respondents from both groups retrospectively rated their perceived confidence levels in restorative skills at the point of graduation via a 5-point Likert scale (1 = not at all confident and 5 = very confident). Group A had a mean score of 3.15 (± 1.01 standard deviation [SD]), whilst group B had a mean score of 2.45 (± 0.8 SD). The confidence levels between the groups were statistically significant, X² (4, N = 94) = 11.59, p = .021. Group A reported that they felt more confident at the point of graduation than Group B, thus reinforcing their decision to not undertake DTFT.

Respondents ranked their perceived confidence levels in restorative skills at one-year post-qualification. Group A had a mean score of 3.47 (± 1.1 SD) whereas Group B had a mean score of 3.91 (± .88 SD). Group A felt less confident in their restorative skills than Group B, X² (4, N = 92) = 11.58, p = .021. Group B felt more confident than Group A after one year, which demonstrates that DTFT schemes did increase perceived clinical confidence.

There was no significant improvement between the perceived confidence levels for Group A at the point of qualification versus one year later, X² (4, N = 120) = 3.73 p = .443. However, Group B showed a statistically significant improvement in perceived confidence levels at qualification versus after completion of DTFT, X² (4, N = 66) = 34.76, p = < 0.00001.

The value of DTFT

Group B respondents were asked which training and educational experiences were of most value and importance to them during DTFT. These were ‘a supportive working environment’ (75.8%, n = 25), ‘the transition from education to independent practice’ (75.8%, n = 25) and ‘gaining clinical confidence’ (78.8%, n = 26) (Fig. 3).

Group B respondents were asked how likely they were to recommend DTFT to other DTs (1 = not at all likely, 5 = very likely). Overall, 81.8% (n = 27) were either likely or very likely to recommend DTFT to their peers. The respondents from both groups were asked whether they agreed with the statement “Postgraduate foundation training for dental therapists should be a mandatory requirement for all graduates”. In Group A, 39.4% (n = 24) agreed or strongly agreed with this statement despite not completing a scheme themselves; however, 29.5% (n = 18) disagreed or strongly disagreed. Group B demonstrated a firm agreement with this statement at 75.7% (n = 25), although 12.1% (n = 4) disagreed even though they had completed a DTFT programme.

Barriers to fulfilling the DT role

Respondents from both groups agreed that they were keen to use and maintain their restorative skills in working practice (Group A 85.3%, n = 52; Group B 81.3%, n = 26). Despite this, approximately two-thirds of respondents had encountered barriers when seeking suitable positions as a DT (Group A 65.6%, n = 40; Group B 66.7%, n = 22) (Table 4).

Table 4

Common barriers faced by DTs seeking job opportunities.
Barrier	Group 1%	Group 2%
1. NHS contract not suitable for implementation of therapy (UDA)	40.0%	58.3%
2. Dentists reluctant or unwilling to refer work to a DT	80.0%	58.3%
3. Practices seeking hygienist only roles	87.5%	75.0%
4. Inadequate time and provision to provide restorative treatment	47.5%	37.5%
5. No nursing support available to facilitate restorative treatment	35.0%	41.7%
6. I have deskilled and I am under-confident in my restorative ability	25.0%	29.2%
7. Dentists don’t know how to uses DTs in practice	2.5%	0.0%
Table 4: Both groups reported encountering barriers when seeking job opportunities.

Further freehand answers were analysed for themes and subthemes and were similar for both groups. Respondents felt undervalued due to a lack of understanding, poor pay and a lack of trust, contractual limitations due to Units of Dental Activity (UDA) and a lack of responsiveness reduced opportunities; and finally, a lack of jobs due to hygiene demand, limited therapy provision and deskilling. However, some respondents reported a steady growth of their role despite the barriers. Most comments focussed on dentists’ attitudes, lack of understanding, the NHS contract, poor remuneration and working conditions – all of which exacerbate the barriers faced and difficulties securing suitable roles.

Theme seven: Undervalued

i. Lack of understanding:

“It is difficult to encourage associate dentists to refer even when all the benefits and positives have been explained.”
“Many GDPs don't understand the Scope of DHTs. They didn't want to refer sometimes, whether it's a cost thing or their lack of trusting someone else to do the work.”

ii. Poor pay:

“I carried out restorative work for the first 2.5 years … but had very poor remuneration.”
“Unable to find reasonably salaried therapist positions with adequate working time.”
“There is no remuneration for the hardest part of our job which is supportive patient prevention.”
“Being paid by completed course of treatments resulted in me being paid less than minimum wage.”

iii. Lack of trust:

“A dentist employed me as a therapist but he found it difficult to let me work alone and stood behind me throughout treatment and eventually took therapy role away from me … my confidence took quite a knock.”
“Constantly second guessed on clinical decisions and questioned on whether I had enough training.”

Theme eight: Contractual

i. UDAs:

“Dentists would prefer the UDAs for themselves.”
“UDA system not suitable for therapy being sent large treatment plans.”

ii. Lack of responsiveness:

“Due to lack of support from NHS contract or acknowledgment of our skills and qualifications there is very limited roles within the NHS and privately.”
“Lack of local anaesthetic prescribing rights causing work flow barriers.”

Theme nine: Lack of jobs

i. Hygiene Demand:

“Hygiene only roles in corporate.”
“Too much demand for hygiene … easier to fill diary with hygiene.”
“Most dental practices offer therapy positions but … when you accept the position it is just hygiene.”
“Hygienist makes more money for the practice.”

ii. Limited therapy:

“Promised therapy and given hygiene.”
“Able to find Dental Therapist job in NHS Community Dental Service, but not in practice.”

Apart from my training practice very few other vacancies.

iii. Deskilling:

“I do worry about de-skilling … due to the current covid climate, coupled with a max exodus of nurses from dentistry … which in turn prevents the execution of restorative treatments”
“When I qualified there were only hygienist roles available in my area. Now I feel I have deskilled.”
“Due to a lack of therapy during my foundation year and covid, I feel I have again deskilled and lost confidence.”

iv. Growth:

“ Initial post was for hyg (sic) but slowly developed the role to be what I wanted proved my skill.”
“I have only now gained sessions in a practice where the principal will utilise my full remit.”
“I have been part of the Thames valley return to work scheme and have gained a locum position as a therapist.”

Covid-19 as a barrier

Covid-19 has been an additional challenge for the dental profession and has impacted on the working practices of DTs; 53% (n = 32) of Group A and 64% (n = 21) of Group B respondents stated that Covid-19 had affected their workload and workflow. Freehand answers were found to have three major themes. Many reported changes in the type of work they were doing, some reported increased hygiene demand whilst others experienced a higher demand in restorative work; these differences may be attributed to the work setting or area of the individuals. However, some reported no difference to work at all, which may be due to the fact that they qualified during the pandemic and know no different. Infection control changes including the need for additional personal protective equipment (PPE) and fallow times also reduced clinical capacity.

Theme ten: Type of work

i. Increase / decrease in restorative work:

“There is a lot of demand for hygiene appointments at the moment and that’s filling up my diary quicker than restorative.”
“Restorative has increased as dentists are so back logged so to need to refer to therapist more than ever before.”
“I have seen A LOT of referrals for heavily broken-down teeth and deep caries, which patients blame on COVID-19 and not being able to access a dentist. However, the way therapists currently feel in my practice is that dentists are prioritising private treatment to get more money, and referring all the dreadful restorative work to us.”

ii. Working environment:

“Increased number of cancellations. Patients wary of attending due to Covid. Mostly older generation.”
“Some patients in high-risk groups have been reluctant to attend. We are now using speed increasing handpieces for restorative work.”
“I have moved to fully private from an NHS practice so that I can continue working with less restrictions. As a result, I see minimal child appointments.”

Theme eleven: No difference

“Wasn’t doing much therapy beforehand and no change as of now.”
“I qualified during Covid so I would not know the difference.”

Theme twelve: Infection control

“Less patients being seen due to need for fallow. I see vulnerable patients who will often cancel due to their own health.”
“Restrictions, fallow, PPE, less patients.”

This study investigated the value of DTFT, and explored how participation may enhance career prospects and established which barriers DTs face when seeking suitable job positions. The respondents to the survey were a small but representative sample population of the DT profession, as the demographic range and working practices showed that respondents were mostly female which represents the population of GDC registered DTs in the UK.⁽¹⁵⁾ Respondents were clear in their reasons for choosing to undertake DTFT or not; and survey responses highlighted shortcomings of the DTFT schemes, despite participants highly recommending them to peers. Barriers which inhibited DTs in fulfilling their scope of practice and finding suitable roles were similar across both groups.

The average age was similar to that in previous UK studies.^{(2, 18)} The majority of respondents worked in general dental practice which was reflective of recent workforce surveys in the UK which found that 87% of DTs work in primary care, with a smaller percentage of respondents who worked in community dental services (CDS).⁽¹⁴⁾ Most respondents worked full-time irrespective of which group they were in; however, Group B reported spending a larger proportion of their working time on restorative procedures and treating a wider range of patients (adults and children) compared to Group A. This difference may be attributed to the additional training that Group B had undertaken and their increased confidence in restorative procedures.

Foundation training schemes for dentists have been widely researched and are reported to be a facilitator in the transition from undergraduate training to independent practice which are beneficial to professional development, clinical competence and confidence levels.^{(8, 29–33)} Foundation training for dentists is mandatory for graduates who wish to hold an NHS performer number.⁽²⁹⁾ There is less UK based literature on the foundation training of DTs with only two papers evaluating a singular DTFT scheme.^{(6, 7)} DTFT is not currently a mandatory requirement for UK DTs, but increasingly more NHSE regions now offer a scheme.

DTs who have completed DTFT report high levels of satisfaction with the training overall; they felt supported, had a range of learning opportunities and felt well integrated into their teams. These findings are reflective of those in the existing UK literature and international studies investigating similar postgraduate training.^{(6, 7, 22, 34)} Despite these positive findings several issues with the DTFT schemes were identified. Many felt that the training practices did not understand enough of the SOP of a DT, that they were being taken advantage of financially, and that the study days were not appropriate. There are financial disparities between DTFT schemes with funding ranging from £5,500 to £24,000 per DT.⁽⁵⁾ These economic inequalities may go some way in explaining why some DTs had better experiences and study days than others. The lack of standardisation across DTFT schemes has been recognised by the recent Advancing Dental Care report which states “HEE will work with stakeholders to develop a national Dental Therapy Foundation Training scheme with a standardised curriculum, based on the experience of HEE regional schemes to date”.⁽⁸⁾

Those who chose not to undertake DTFT cited reasons including feeling confident to start work without it, financial implications, not knowing it was an option, and not having the opportunity due to geographic restrictions. The first DTFT scheme was introduced to prevent newly qualified DTs working solely as hygienists and to encourage them to work in NHS general practice.⁽⁶⁾ However, there is a strong inference that some DTs felt that DTFT schemes are only for those who are under-confident. There appears to be a lack of understanding about the broader benefits of participating in DTFT beyond improving confidence levels. Interestingly, a main reason for not undertaking DTFT was the salary and a stance of being viewed as “cheap labour” and desires to earn their worth elsewhere. The relationship between feeling professionally valued and remuneration is closely entwined and neither the DTFT schemes or practices offering DT roles have struck a reasonable balance for many. As a result, the DTFT schemes may not be reaching as wide a cohort of DTs as intended, with many missing out on valuable experiences due to pay and the experiences of their peers. This has the potential to change with a wider selection of schemes in the future and standardisation of the curriculum. Contrary to DTs, dentists accept foundation training as part of their educational and career pathway.

Workforce planning measures over the past decade have cut dental student intake to reflect projections of workforce demand.⁽³⁵⁾ Alongside this, increasing numbers of DTs are registering annually, the latest figures report 525 new DT registrants entering the GDC register in 2020 and 323 in 2019.⁽³⁶⁾ However, there are reports of overseas dentists registering as hygienists and DTs which may account for these high numbers.⁽³⁷⁾ Despite workforce changes to meet the needs of the population, DTs report encountering many barriers when seeking suitable workplaces and job positions. The barriers encountered by the respondents were the same for both groups, completing DTFT did not reduce barriers or obstacles for DTs.

The business aspects of dentistry such as a lack of a performer number, the NHS UDA system and the current NHS dental contract were cited as significant obstructions to securing DT positions and fulfilling the SOP. These barriers are widely acknowledged by the profession and this qualitative research supports the findings of the previous literature, that the current remuneration system limits delegation to DTs.^{(19, 38–41)} Contrary to these findings, workforce planning and operational modelling studies suggest that optimal skill-mix and implementation of DTs has significant cost-saving potential for NHS services.^{(13, 42–44)} Furthermore, correct utilisation of DT skills has a potential to increase access to dental care and improve oral health through delegation of up to 77% of clinical time to DTs.^{(13, 19, 45)} In July 2022 the NHS announced reforms to the 2006 contract, including addressing misunderstandings around skill-mix in NHS dental services and removal of administrative barriers which prevent DTs from fulfilling their full SOP.⁽⁴⁶⁾ However, there are professional misgivings around this reform with the British Dental Association having taken a neutral stance.⁽⁴⁷⁾

Another significant barrier faced by DTs is a culture of being undervalued as clinicians. A lack of trust from dentists, lack of nurse support and poor working conditions were commonplace for respondents. These findings align with previous studies which found poor job satisfaction amongst DTs.^(18–20) The perceptions of dentists towards DTs has been well documented and supports the experiences of the respondents; there is a lack of awareness of the DT SOP and reservations about their training and competence.^{(19, 45, 48)} This lack of acceptability limits job opportunities and as a result DTs are fulfilling roles which focus on hygiene and periodontal treatment. Most of the respondents were keen to use and maintain their restorative skills in the future, but the job market was viewed as restrictive for DTs with many practices looking solely for hygienists, or advertising for DTs and then only referring hygiene patients. The existing literature reflects this finding with reports of low numbers of DTs fulfilling their full SOP.^{(2, 21)} DTs who do not fulfil their SOP are at risk of deskilling and this was a reality for several respondents despite extra training and efforts to maintain their skills.

In addition, the Covid-19 pandemic has been a major obstacle for the dental profession which has seen an increase in demand for dental appointments and increased strain on services.^{(24, 25)} The majority of DTs reported that their work changed as a result of the pandemic, some described an increase in hygiene demand whilst others experienced increased demand in restorative work. These differences may be attributed to where in the UK the DT was practicing, the demographic of the patients, the existing working patterns and practices of the DT, or the type of practice they were working in. Many challenges were also created due to working in a high-risk environment such as new infection control measures.⁽²³⁾

A strength of this study was the approach of both open and closed questions which allowed for triangulation and purposeful integration of the data, which augments findings of the research and supports researchers in taking a panoramic view and understanding of the participants’ responses.⁽⁴⁹⁾ However, a limitation of this study was the response rate of 94 which is low compared to the number of GDC registered DTs. A larger sample size may have produced further data on the experiences of DTs. It is not possible to accurately quantify the response rate because it is unknown how many members of the BADT there are or how many members of the social media group saw or interacted with the survey invitation.

There is a possibility of sampling bias with this method of recruitment; however, the respondents demonstrated a wide demographic and working range which is representative of UK DTs. Caution should be observed when considering the findings of this study as the qualitative findings can only be applied to the research sample and are therefore not generalisable across the whole DT population.⁽⁵⁰⁾ Another consideration is the possibility of researcher bias when interpreting the qualitative data. Initial analysis of the qualitative data was undertaken independently, but researcher bias should be acknowledged as all the researchers are from a dental background. This was minimised by practicing reflexivity throughout the research process.^{(28, 50)}

Within the scope of this investigation, DTFT schemes were viewed as a valuable educational experience which increased perceived clinical confidence when compared to DTs who did not undertake additional vocational training. The DTs who completed DTFT reported that the extra training enhanced their job prospects and they secured a position as a DT as a result of DTFT. Participation in a DTFT scheme may enhance career prospects when compared to DTs who did not undertake DTFT. Whilst the work settings were the same across both groups, the DTFT cohort reported more variation in their working practice with regard to patient groups and being able to practice their full SOP. Despite this, barriers were encountered by DTs from both groups which limit career progression.

The authors declare no competing or conflict of interests.

ACKNOWLEDGEMENTS

With thanks to the 94 dental therapists who took the time to complete the survey and to the BADT for distributing the survey.

LEGCK, CL and DRR contributed to the design of the research survey. LEGCK and DRR were responsible for the analysis of the results and the writing of the manuscript. CL reviewed the manuscript. CMV assisted with statistical analysis. The final version of the manuscript was approved by all authors.

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There is no duality of interest

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Evaluation of Postgraduate Foundation Training for Dental Therapists: Does participation enhance career prospects?

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INTRODUCTION

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