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SP Paper 277
 
 

ACCESS TO DENTAL HEALTH SERVICES IN SCOTLAND

Professor Tim Newton, Professor Alison Williams and Dr Elizabeth Bower
Department of Oral Health Services Research & Dental Public Health GKT Dental Institute, London

COMMISSIONED BY THE SCOTTISH PARLIAMENT INFORMATION CENTRE FOR THE HEALTH COMMITTEE

TABLE OF CONTENTS

EXECUTIVE SUMMARY

1. INTRODUCTION

1.1 Aim of the study
1.2 Context
1.3 Defining access
1.4 Measuring access
1.5 Can accessing dental services improve oral health?
1.6 Summary

2. ANALYSIS OF EXISTING INFORMATION

2.1 Oral health in Scotland
2.2 Information on General Dental Service

2.2.1 Workforce modelling
2.2.2 Data from MIDAS

2.3 Information on Community Dental Service
2.4 Information on Hospital Dental Service
2.5 Summary

3. AIMS AND OBJECTIVES

4. METHOD

4.1 Questionnaire
4.2 Administration of questionnaire
4.3 Data entry and analysis
4.4 Modelling access
4.5 Non-respondents
4.6 Ethical approval
4.7 Summary

5. RESULTS

5.1 Response rate
5.2 Non-respondents

5.2.1 Summary

5.3 Description of the respondents

5.3.1 Summary

5.4 Dentist to population ratios

5.4.1 Dentist to population ratios at a Health Board and a national level
5.4.2 Estimating the number of dentists providing NHSScotland services in each Health Board
5.4.3 Estimating the number of Whole Time Equivalent Dentists available to NHSScotland
5.4.4 Effect of lower output from salaried GDS practitioners
5.4.5 Summary

5.5 Relationship between supply and utilisation of dental services

5.5.1 Summary

5.6 Relationship between access to services and indicators of need for dental services

5.6.1 Relationship between supply and need
5.6.2 Relationship between utilisation and need
5.6.3 Recalculating dentist to population ratios to account for need
5.6.4 Summary

5.7 Availability of NHSScotland time

5.7.1 Proportion of time spent on NHSScotland dental services
5.7.2 Working hours according to age and gender
5.7.3 Trends in NHSScotland working hours
5.7.4 Summary

5.8 Other indicators of access to NHSScotland primary care services

5.8.1 Provision of NHSScotland dental care for children
5.8.2 Provision of NHSScotland dental care for adults
5.8.3 Waiting times for routine NHSScotland treatment
5.8.4 Distances travelled by patients to surgery/clinic
5.8.5 Evening and weekend appointments
5.8.6 Wheelchair access
5.8.7 Domiciliary care
5.8.8 Emergency care
5.8.9 Numbers of registered patients
5.8.10 Professionals Complementary to Dentistry
5.8.11 Summary

5.9 Access to NHSScotland specialist services

5.9.1 Specialist dental practitioners in general dental practice
5.9.2 Distance of dental practice from specialist facilities
5.9.3 Summary

5.10 Access to NHSScotland dental services in rural locations

5.10.1 Summary

5.11 Recruitment and retention

5.11.1 Recruitment
5.11.2 Retention
5.11.3 Summary

5.12 Improving access to NHSScotland dental services in the future

5.12.1 Anticipated increase in time spent treating NHSScotland patients
5.12.2 Incentives to encourage greater participation in NHSScotland
5.12.3 Respondents currently not working for NHSScotland but who may return to such employment

5.12.3.1 Incentives to return to providing NHSScotland services for retired dentists
5.12.3.2 Individuals on maternity leave or taking another career break

5.12.4 Summary

5.13 Summary of access to NHSScotland dental services

5.13.1 Availability
5.13.2 Accessibility
5.13.3 Accommodation
5.13.4 Comparing access between Health Boards
5.13.5 Summary

6. PROJECT REVIEW

6.1 Overview of the study
6.2 Relating the findings to current NHSScotland policy
6.3 Limitations of the study
6.4 Summary

BIBLIOGRAPHY

APPENDIX 1 QUALITATIVE DATA

Financial issues
Recruitment of dentists

Recruitment and retention in rural areas

Secondary and tertiary care

Few NHS consultant posts advertised

Morale

APPENDIX 2 GLOSSARY OF TERMS AND ABBREVIATIONS

APPENDIX 3 COPY OF QUESTIONNAIRE

APPENDIX 4 COPY OF LETTER TO PARTICIPANTS


ACCESS TO DENTAL HEALTH SERVICES IN SCOTLAND

Professor Tim Newton, Professor Alison Williams and Dr Elizabeth Bower
Department of Oral Health Services Research & Dental Public Health GKT Dental Institute, London

COMMISSIONED BY THE SCOTTISH PARLIAMENT INFORMATION CENTRE FOR THE HEALTH COMMITTEE

Executive Summary

On 1 April 2004, the Scottish Parliamentary Corporate Body, on behalf of the Health Committee, commissioned the research team to survey the population of Scottish dentists with the aim of:

  • Identifying their contribution to the provision of National Health Service dental services in Scotland.

  • Identifying areas where the availability of such services is insufficient to meet the need or demand.

Defining access

Access can be defined as the as the ability of clients to utilise and benefit from oral health care and is the degree of fit between the client and the health care system. Access to health care services has both supply and utilisation components (see sections 1.3-1.6).

Review of existing information

Data on oral health in Scotland demonstrated a wide variation in the oral health of children between Health Boards. There was no information on adult oral health at a Health Board level. However, adults and children living in deprived areas experienced more dental disease than people living in affluent areas (see section 2.1).

A review of data on general dental services, the community dental service and the hospital dental service (see sections 2.2-2.5), highlighted a lack of information on the numbers of Whole Time Equivalent (WTE) NHSScotland dentists working in all fields of dentistry at a Health Board level. There was also little information at a Health Board level on the structural dimensions of access such as the numbers of dentists accepting new NHSScotland patients, distances travelled by patients for primary and secondary dental care, the availability of evening/weekend appointments, and access for groups with special needs etc. This applied to all sectors of dentistry. More information was also required at a Health Board level on the demand for access to general dental services. Data on the need and demand for community dental services at both a national and a Health Board level was also lacking. In the hospital dental sector, more information was needed on the utilisation and need for services at both a national and a Health Board level. There was a need for data on the recruitment and retention of all dental staff. In order to obtain this information, a questionnaire survey of dental practitioners within Scotland was undertaken.

Method

A postal questionnaire survey of all dentists registered with the General Dental Council in 2004 at an address in Scotland was conducted (see section 4). The survey was conducted in accordance with evidence to maximise response rates (Edwards, 2002). Questionnaires were posted to a total of 2852 dental practitioners in June 2004 with two further mail-outs in July and August 2004. The response rate for the survey was 74.8% (see section 5.1). An analysis of non-respondents suggests that there may be a degree of non-response bias in the findings. Non-respondents were more likely to have been from urban Health Boards and to have qualified more recently (see section 5.2).

Using a model of access described by Penchansky & Thomas (1981), three key dimensions of access were used to assess access to NHSScotland dental services (see section 1.4):

  • Availability (e.g. dentist to population ratios, proportion of time dentists spend providing NHSScotland dental services)

  • Accessibility (e.g. proportion of primary care dentists accepting patients for NHSScotland care, wheelchair access, distances travelled to the surgery)

  • Accommodation (e.g. waiting times for treatment, availability of evening/weekend appointments)

The study mainly used supply rather than utilisation indicators to assess access to dental services, although registration rates with General Dental Practitioners (GDPs) by Health Board were examined as a measure of utilisation (see section 5.5). Because of the lack of information on oral health need for adults at a regional level, the study used information on deprivation levels to estimate oral health need (see section 5.6). The impact of demand on access was not assessed due to a lack of data on demand at a regional level. Most of the indicators reflected primary care provision[1], given that the majority of oral health care in Scotland is provided in primary care locations.

The study also looked at other issues relating to access such as incentives to increase NHSScotland provision, incentives to return from retirement to provide NHSScotland services, and recruitment and retention problems (see sections 5.12.2, 5.12.3 and 5.11 respectively).

The guiding principle informing assessment of the various dimensions of access at a Health Board level was equity of access in relation to need.

Availability

Indicators of availability pertained to all dentists, irrespective of field of dentistry, and are described in sections 5.4-5.7. The availability of professionals complementary to dentistry (PCDs) was not considered . The dentist to population ratio for Scotland as a whole was 5.57 dentists per 10,000 population. However, when taking into consideration part time working and the provision of private services, the WTE NHSScotland dentist to population ratio fell to 3.53 dentists per 10,000 population. WTE NHSScotland dentist to population ratios, corrected for the lower output of salaried general dental service (GDS) practitioners, varied widely between Health Boards with the highest availability of dentists in Greater Glasgow and the lowest availability in Dumfries & Galloway.

Registration rates were significantly higher in areas where there were more GDS dentists available, suggesting that increasing the dentist to population ratio in an area is a way of improving the utilisation of services in that area.

There were significantly more GDS dentists in areas of deprivation. Registration rates for children were also significantly higher in deprived areas.

There was a wide variation in the proportion of time dentists spent providing NHSScotland services between Health Boards, ranging from 99.5% in the Western Isles to 64.5% in the Highlands. Overall, 26% of dentists had decreased their NHSScotland time in the recent past, but the proportion was greater in general dental practice. Female practitioners aged 30-49 years and older practitioners worked fewer hours.

Accessibility

Indicators of accessibility referred to primary care services only and are described in section 5.8. Most primary care dentists provided NHSScotland services. Fifty-eight percent of primary care dentists were offering appointments to new child patients, but only 37% were accepting all categories of adults as new patients. Access for children to NHSScotland services broadly matched that of adults, and varied widely across Health Boards. Orkney had the greatest proportion of primary care dentists accepting new children and adults, whereas Borders had the lowest proportion with more than 80% primary care dentists in the area not accepting new patients or having a waiting list.

Sixty-one percent of primary care dentists worked in surgeries which were wheelchair accessible. Wheelchair access varied between Health Boards and was best in Shetland. Wheelchair access was also better in primary care centres managed by Health Boards than in general dental practice.

Patients travelled an average of 24.5 miles to access NHSScotland primary dental care services, but those attending clinics in rural areas, particularly in the Highland Health Board, and those attending specialist services travelled further.

Accommodation

Indicators of accommodation applied to primary care services only and are described in section 5.8. Accommodation was poor in the Health Boards with the lowest population density. Overall, patients had to wait an average of 4.5 weeks for routine NHSScotland dental treatment, but again this varied between Health Boards with the longest waits in Orkney and the shortest waits in Greater Glasgow. Waiting times for salaried GDS dentists employed by Health Boards were twice that of dentists in general dental practice.

Just over a third of dentists provided evening and weekend appointments for NHSScotland patients. Dentists in general dental practice were more likely to provide such appointments than other primary care groups and thus Health Boards with greater proportions of dentists working in general dental practice had better evening and weekend provision.

Access to specialist services

There were problems with access to NHSScotland specialist services in both rural and urban areas (see section 5.9). Waiting times for some specialist services were high for some specialities in Lothian, Greater Glasgow, Borders and Dumfries & Galloway. There were marked differences between Health Boards in the distances patients had to travel to access specialist NHSScotland services. Shetland was particularly poorly served in this regard. Patients travelled further for restorative dental services than other services.

There were few specialist practitioners providing NHSScotland services in general dental practice and most were orthodontists. Patients travelled further, and waited longer to see such practitioners than other primary care dentists, and more than half the specialist practitioners were not accepting new patients or were using a waiting list.

Access to dental services in rural areas

Data on access to dental services in rural areas are described in section 5.10. There were NHSScotland dentists working in rural areas in most Health Boards. There were more problems in relation to accessibility and accommodation in rural areas. The use of salaried GDS dentists to improve access to primary care dentistry has been relatively successful in some remote areas such as Orkney and Shetland. However, other research indicates that such services are relatively inefficient and in this study, salaried GDS services provided by Health Boards performed less well on other indicators of access such as the availability of evening and weekend appointments, and waiting times for routine treatment.

Recruitment and retention

Recruitment and retention problems were most common for GDPs and dental nurses, and there was a particular retention problem for dental nurses (see section 5.11). Orkney and the Western Isles had the worst recruitment and retention problems of all the Health Boards. There was no relationship between such problems and deprivation scores.

Incentives to encourage greater participation in NHSScotland  

Only 3.5% of primary care dentists stated that they intended to increase the amount of time spent treating NHSScotland patients over the next two years (see section 5.12.1). No incentive to increase NHSScotland commitment was favoured by the vast majority of practitioners. The most frequently endorsed incentive was a significant increase in the fee per item of treatment (55% primary care dentists). Moves to a salaried contract or a capitation arrangement were far less popular (see section 5.12.2). 62% of retired dentists could see no incentive to induce them to return to providing NHSScotland dental services and thus plans to increase provision of services by encouraging retired dentists to return to practice are unlikely to be successful (see section 5.12.3).

A significant increase in NHSScotland provision, required to meet pledges to make free NHSScotland check-ups available to all by 2007, and improve access to dental services, is more likely to succeed where the incentives on offer appeal to the greatest proportion of dentists. This is unlikely to be achieved with the type of incentives currently available.

Conclusions

Most Health Boards varied in how they performed in the different dimensions of access (see section 5.13). A summary of the performance of each Health Board in relation to the dimensions of access identified in this report is given as Table I, and depicted in Figures I to XI below. Overall, Dumfries & Galloway and Borders had the worst access in terms of availability, accessibility and accommodation, and Lanarkshire and Argyll & Clyde had the best access. The problem issues varied between Health Boards, rural and urban areas, and between primary and secondary care services.

Solutions to the problems of access identified in this report are likely to be required to operate at two levels. While local commissioning of services should be sufficiently flexible to allow services to correct problems of access at the local level, a broader national strategy is required to ensure that practitioners receive adequate incentives to commit to NHSScotland. Increasing NHSScotland provision overall is unlikely to be achieved with the type of incentives currently available.

The current research has addressed several of the deficiencies identified from the review of existing literature, but some issues were not explored in the study. Specifically, there is a need to assess the impact of PCDs on access. At a Health Board level, the demand for oral health services is not known and data is required on the need for adult oral health services. Investigating the effectiveness and efficiency of access to services at a Health Board level is also another potential area of research.

Table I Summary of access by Health Board based on indicators of supply (pdf)

Figure I Health Boards grouped according to 2001 Carstairs deprivation scores (pdf)

Figure II Health Boards grouped according to WTE NHSScotland dentist to population ratios (pdf)

Figure III Health Boards grouped according to WTE NHSScotland dentist to population ratios taking into account lower output of salaried GDS service (pdf)

Figure IV Health Boards grouped according to WTE NHSScotland dentist to population ratios taking into account lower output of salaried GDS services and deprivation levels (pdf)

Figure V Health Boards grouped according to the proportion of the working week dentists spent providing NHSScotland dental services (pdf)

Figure VI Health Boards grouped according to proportion of primary care dentists not accepting new children for NHSScotland dental care or using a waiting list (pdf)

Figure VII Health Boards grouped according to proportion of primary care dentists not accepting new adults for NHSScotland dental care or using a waiting list (pdf)

Figure VIII Health Boards grouped according to proportion of primary care dentists working in surgeries with wheelchair access (pdf)

Figure IX Health Boards grouped according to the furthest distance patients travelled from their home to the primary care surgery in an average week (pdf)

Figure X Health Boards grouped according to average waiting time forthe provision of routine treatment in primary care (pdf)

Figure XI Health Boards grouped according to the proportion of primary care dentists offering evening/weekend appointments for NHSScotland patients (pdf)

1. INTRODUCTION

1.1 Aim of the study

On 1 April 2004, the Scottish Parliamentary Corporate Body, on behalf of the Health Committee, commissioned the research team to survey the population of Scottish dentists with the aim of:

  • Identifying their contribution to the provision of National Health Service dental services in Scotland.

  • Identifying areas where the availability of such services is insufficient to meet the need or demand.

This report first identifies the information that already exists regarding dental services and describes how the research will complement or improve on it. It then outlines the methods used in creating and undertaking the survey. Finally, the data from the survey is presented and the findings are discussed.

1.2 Context

The White Paper Towards a Healthier Scotland. A White Paper on Health (The Scottish Office Department of Health, 1999) identifies dental health as a key area for action. The White Paper sets a headline target that 60% of 5 year olds should have no experience of dental disease by 2010, and a second rank target that less than 5% of 45-54 year olds should have no natural teeth by 2010.

Plans to improve dental service availability and access are outlined in An Action Plan for Dental Services in Scotland (Scottish Executive, 2000a), and are part of a broader plan to achieve the oral health targets detailed above. The proposals to improve access focus on a number of issues including the employment of salaried dental practitioners in deprived and rural areas; enabling attendance at the dental surgery through the establishment of drop-in centres in major cities and expanding the use of mobile services; rewarding General Dental Practitioners (GDPs) for their commitment to providing NHSScotland services; and improving the availability of oral health information and advice to the population.

Improving patient access to NHSScotland services is a stated priority in the report Our National Health; a plan for action; a plan for change (Scottish Executive, 2000b). The report suggests that remote and rural Scotland has particular needs which should be addressed, and the need for solutions specifically tailored to meet the needs of local communities is discussed in Rural Scotland: A New Approach (Scottish Executive, 2002a).

The need to improve access to dental services for children is discussed in the consultation document Towards Better Oral Health in Children (Scottish Executive, 2002b). The report emphasises the need for the transition from a treatment-based to a prevention-orientated dental service which is well integrated with wider oral health promotion activities for children.

Workforce planning in NHSScotland is central to plans to improve access and has received particular attention in recent years (Scottish Executive, 2002c; 2002d). Within dentistry, a number of workforce planning reports have been published in Scotland since 2000 (Scottish Advisory Committee on the Dental Workforce, 2000; Scottish Executive, 2002e; Scottish Council for Postgraduate Medical and Dental Education/ISD Scotland, 2002), culminating in Workforce planning for dentistry in Scotland (NHS Education for Scotland/ISD Scotland, 2004). The aim of the latest report is to provide an evidence-based dental workforce planning mechanism to support the strategic development of dental services in NHSScotland. Supply, utilisation and demand are considered in predicting the numbers of GDPs required in general dental services in the future.

The education and training of the dental team, including professionals complementary to dentistry (PCDs), is an important factor in improving access to services and is addressed in A Strategy for the Development of Education and Training for the Dental Team in Scotland (NHS Education for Scotland, 2002). Changes in the use and training of PCDs, undergraduate training, dental vocational training, specialist training and continuing professional development for GDPs are described. Education and Training for the Dental Team in Remote and Rural Regions of Scotland (NHS Education for Scotland, 2003) suggests a number of initiatives for improving education and training in rural and remote areas, including capital and revenue funding, workforce development and the strengthening of networks within dentistry.

The recent consultation paper Modernising NHS Dental Services in Scotland (Scottish Executive, 2003a) builds on an undertaking in the White Paper Partnership for Care (Scottish Executive, 2003b:54) that the Scottish Executive would ‘take forward proposals for changes to the system for rewarding primary care dentistry in order to…improve access to services’. The principle of ‘equitable access and service provision’ is stated as underpinning plans for modernising and developing dental services in Scotland (Scottish Executive, 2003a:13).

Following the consultation, the Scottish Executive introduced the Smoking, Health and Social Care (Scotland) Bill on 16 December 2004. Part 2 of the Bill concerns general dental services. It includes proposals for the following:

  • Free oral health assessments and dental examinations for all. The Scottish Executive believes this will help to detect early signs of disease, illness or injury (Policy Memorandum, 2004:7).

  • Breaking the current link between the GDS item of service fees paid to dentists and the patient charges levied. . The Bill does not provide for a new patient charging system but creates a new framework that will allow Scottish Ministers to introduce a new system through regulation at some point in the future.

  • Allowing NHS Boards to take a more active role in securing and providing GDS. The Scottish Executive intends that there will be a national framework for GDS supplemented by local arrangements for services outwith the framework. The Bill itself does not propose a new payment arrangement, but would allow Scottish Ministers to introduce changes through regulations.

1.3 Defining access

Access to oral health care can be defined as the ability of clients to utilise and benefit from oral health care (Royal College of General Practitioners, 1985, adapted). It is essentially the degree of fit between the client and the health care system (Penchansky & Thomas, 1981). Access is a core feature of a quality health service (Maxwell, 1984) and is a multifaceted phenomenon, encompassing issues such as:

  • the policies, resources, organisation and financing of the dental care system

  • predisposing characteristics of the population to seek services such as age, ethnicity, social class, general health, oral health beliefs, perceptions of need

  • enabling resources such as personal income; relationships which reinforce oral health behaviours; location, availability, and acceptability of local dental services

  • use of health services

  • oral health behaviours

  • oral health outcomes

(Andersen, 1995; Penchansky & Thomas, 1981)

The concept of equity of access to health care for people in equal need has been a central objective of the NHS since its inception in 1948 (Goddard & Smith, 2003). Access should also be effective in terms of health improvement through accessing services, and efficient in terms of meeting need without significant over or under provision of care (Andersen & Davidson, 2001).

Access to oral health care has most often been taken to refer to access to oral health care services, for example, those provided by a dental practitioner. While this report will focus most on such an approach, it should be noted that the term ‘health care’ includes a broader range of determinants of health than dental services. Starting Well, a health education project with a significant oral health component in Greater Glasgow, is an example of oral health care which reaches beyond dental services.

1.4 Measuring access

Access to health services is often measured in one of two ways. The structural approach considers the supply of services, that is, whether a service exists, is available and whether systems are in place which allow service utilisation (Starfield, 1992). A useful model of access is provided by Penchansky & Thomas (1981). The model identifies five inter-related characteristics of access:

  • Availability (e.g. distribution of health services, dentist to population ratios)

  • Accessibility (e.g. location of services, ability to register at a practice as a new patient, access for disabled patients)

  • Accommodation (e.g. opening hours, waiting times, availability of drop-in services)

  • Affordability (e.g. cost of services, cost of taking time off work to receive service)

  • Acceptability (e.g. cultural concordance between dentist and patient, language compatibility)

It is possible for a population to have access to services but not use them; the structural approach largely omits the analysis of individuals’ interaction with the healthcare system. In contrast, the process approach measures the utilisation of dental services ( Gibson, 2003). Rates of utilisation such as dental registration rates have been suggested as objective indicators of access and are relatively easy to measure. However, utilisation as a measure of access must be considered within the context of its outcome. For example, registration rates are often used as a measure of utilisation, yet it is possible for a patient to be registered at a dental surgery but not be able to obtain an emergency appointment, appropriate treatment, or necessary oral health advice at the surgery.

Both supply and utilisation measures are more useful if explored together, and integrated with information on need, demand, and oral health outcomes, though it can be difficult to be sure that an oral health outcome is the direct result of access to dental services (Wareham et al, 2001).

One difficulty in measuring access is the question of what kind of service is being accessed. It is usually assumed that the purpose of access to dental services is to access treatment, and the data available on dental service activity such as that supplied by MIDAS reinforces this assumption. However, for oral health to improve, it may be necessary for dental services to have a much greater focus on prevention rather than restoration. Furthermore, equality of access to health care is not the same as equality of treatment, or equality of health outcome (Goddard & Smith, 2003).

1.5 Can accessing dental services improve oral health?

It is generally assumed that the purpose of access to dental services is to enhance or maintain oral health, and recent research has shown that the use of such services can impact positively on oral health (Locker, 2001).

However, the determinants of oral health extend far beyond access to dental services and include environmental conditions such as water fluoridation; education; social, cultural, political and economic factors which impact at a national, community and individual level; individual lifestyle factors such as diet, smoking, and oral hygiene practices; natural, genetic and biological variation (Dahlgren & Whitehead, 1991). Dental service utilisation alone does not necessarily enhance or maintain oral health (Andersen & Davidson, 1997). Other oral health enhancing activities might include oral health promotion, water fluoridation, education, legislation (for example, with regard to smoking) and addressing social, cultural and economic deprivation.

1.6 Summary 

  • The study was commissioned with the aim of identifying the contribution of all Scottish dentists to the provision of National Health Service dental services in Scotland, and identifying areas where the availability of such services is insufficient to meet the need or demand

  • The principle of equitable access to dental services in Scotland underpins plans for modernising and developing dental services in Scotland

  • Access is the degree of fit between the client and the health care system, and can be defined as the as ability of clients to utilise and benefit from oral health care

  • Access to health care services has both supply and utilisation components

  • Access should be equitable in relation to oral health need, effective in improving oral health status, and efficient in terms of meeting need without over provision of services

  • Penchansky & Thomas (1981) provide a framework of five dimensions to describe the structural aspects of access, which are key determinants of service utilisation

  • The determinants of oral health extend far beyond access to dental services and dental service utilisation alone does not necessarily enhance or maintain oral health.


Footnotes:

[1] Primary care dentists are practitioners working in general dental practice and the community dental service, and include salaried general dental service dentists employed by Health Boards.