Use of the out-of-hours emergency dental service at two south-east London hospitals

  • Rupert Austin1,

    Affiliated with

    • Kate Jones1, 2,

      Affiliated with

      • Desmond Wright1, 3,

        Affiliated with

        • Nora Donaldson4 and

          Affiliated with

          • Jennifer E Gallagher1, 5Email author

            Affiliated with

            BMC Oral Health20099:19

            DOI: 10.1186/1472-6831-9-19

            Received: 08 December 2008

            Accepted: 25 July 2009

            Published: 25 July 2009

            Abstract

            Background

            Prior to the introduction of the 2006 NHS dental contract in England and Wales, general dental practitioners (GDPs) were responsible for the provision of out-of-hours (OOH) emergency dental services (EDS); however there was great national variation in service provision. Under the contractual arrangements introduced 1st April 2006, local commissioning agencies became formally responsible for the provision of out-of-hours emergency dental services. This study aimed to examine patients' use of an out-of-hours emergency dental service and to determine whether the introduction of the 2006 national NHS dental contract had resulted in a change in service use, with a view to informing future planning and commissioning of care.

            Methods

            A questionnaire was administered to people attending the out-of-hours emergency dental service at two inner city London hospitals over two time periods; four weeks before and six months after the introduction of the dental contract in April 2006. The questionnaire explored: reasons for attending; dental registration status and attendance; method of access; knowledge and use of NHS Direct; satisfaction with the service; future preferences for access and use of out-of-hours dental services. Data were compared to determine any impact of the new contract on how and why people accessed the emergency dental service.

            Results

            The response rate was 73% of attendees with 981 respondents for the first time period and 546 for the second. There were no significant differences between the two time periods in the gender, age, ethnic distribution or main language of service users accessing the service. Overall, the main dental problem was toothache (72%) and the main reason for choosing this service was due to the inability to access another emergency dental service (42%). Significantly fewer service users attended the out-of-hours emergency dental service during the second period because they could not get an appointment with their own dentist (p = 0.002 from 28% to 20%) and significantly more service users in the second period felt the emergency dental service was easier to get to than their own dentist (P = 0.003 from 8% to 14%). Service users found out about the service from multiple sources, of which family and friends were the most common source (30%). In the second period fewer service users were obtaining information about the service from dental receptionists (P = 0.002 from 14% to 9%) and increased use of NHS Direct for a dental problem was reported (P = 0.002 from 16% to 22%) along with more service users being referred to the service by NHS Direct (P = 0.02 from 19% to 24%). The most common preference for future emergency dental care was face-to-face with a dentist (79%).

            Conclusion

            This study has provided an insight into how and why people use an out-of-hours emergency dental service and has helped to guide future commissioning of these services. Overall, the service was being used in much the same way both before and after the 2006 dental contract. Significantly more use was being made of NHS Direct after April 2006; however, informal information networks such as friends and family remain an important source of information about accessing emergency dental services.

            Background

            On 1st April 2006 new NHS dental contracts and new patient charges for NHS dental services were introduced to England and Wales. As part of this contractual change, primary care trusts (PCTs) in England became formally responsible for out-of-hours dental services [1]. There was media and public concern that the new arrangements might have resulted in dentists moving away from the provision of NHS dental services to the independent sector thereby reducing availability of NHS dental care [2]. Concern was also expressed that the new patient charging system could mean increased charges for people who opt for occasional rather than routine care. The resulting effect could be an increased demand and change in patterns of use of out-of-hours dental services.

            Qualitative research on how and why people access emergency services suggests that advice and reassurance may be just as important as pain relief and that many attendees at a walk in emergency dental service would be happy with advice and a reliable appointment once surgeries re-opened [3, 4]. Research in medical emergency departments highlights difficulty in accessing GPs as the major reason why people with primary care problems attend accident and emergency departments [5]. A survey of nationwide out-of-hours emergency dental service arrangements in the UK reported wide geographical variation in the provision of services, whilst local studies have reported relative dissatisfaction with walk-in arrangements [6, 7], and improved access following the introduction of telephone triage [810].

            The inner-city London boroughs of Lambeth, Southwark and Lewisham have had two established emergency dental services that were set up during the 1990s. These walk-in services were provided from King's College Hospital and Guy's Hospital. King's operated a two surgery system on weekday evenings and weekend and Bank Holiday mornings whereas the Guy's service only operated on weekends and bank holidays. Both services were funded by the local primary care trusts and staffed by local dentists. Most people self-referred; however, referrals were also made from various sources, including NHS Direct and local accident and emergency services. Both registered and non-registered NHS dental people used the service.

            Information on how or why people access out-of-hours emergency dental services was required locally in Lambeth, Southwark and Lewisham to inform local commissioning under the new out-of-hours service arrangements. The study was also designed to provide a measure of the impact of the 2006 NHS dental contract on people's use of out-of-hours emergency dental services.

            The aim of the study was to determine patterns of service use of the Lambeth, Southwark and Lewisham out-of-hours emergency dental service and to determine whether the introduction of the 2006 dental contract resulted in a change of patterns of attendance, characteristics of attendees and attitudes relating to attendance. This would inform future planning and commissioning of care.

            Methods

            The study was designed as a two-stage cross-sectional questionnaire based survey. A questionnaire was administered during two time periods (March 2006 and October 2006) to all adults seeking dental care at the out-of-hours emergency dental services provided within Lambeth, Southwark and Lewisham. The questionnaire was developed using published research on how and why people access OOH EDS [6, 10], and past local unpublished research into the characteristics of patient attending the emergency dental services in South East London. The questionnaire was piloted on 20 people prior to the start of the study. The principal inclusion criteria were all adult attendees who consented to participate in the study and who saw a dentist during their visit. Principal exclusion criteria were violent/aggressive/abusive attendees and children (17 and younger). Ethical approval was granted from The Central Office for Research Ethics Committees (COREC) and Research Governance approval was granted from King's College Hospital and Guy's and St Thomas' NHS Foundation Trusts and from Southwark PCT on behalf of Lambeth, Southwark and Lewisham PCT's.

            In order to show equivalence of proportions of between 5% and 10%, with a maximum acceptable difference of 7%, an effective sample of 514 subjects was required for each time period. It was envisaged that the number of people recruited was going to be three to four times as large in King's in relation to Guy's due to the difference in the number of service users between each site. A questionnaire was administered to service users at the out-of-hours emergency service, on both hospital sites, by an administrator recruited and trained specifically for this task (Figures 1, 2).
            http://static-content.springer.com/image/art%3A10.1186%2F1472-6831-9-19/MediaObjects/12903_2008_Article_128_Fig1_HTML.jpg
            Figure 1

            Section A of questionnaire administered to service users attending an out-of-hours emergency service.

            http://static-content.springer.com/image/art%3A10.1186%2F1472-6831-9-19/MediaObjects/12903_2008_Article_128_Fig2_HTML.jpg
            Figure 2

            Section B of questionnaire administered to service users attending an out-of-hours emergency service.

            The administrator invited patients to take part and asked them to complete the questionnaire in the waiting room. The themes of the questionnaire included:
            • ◦ Section A (Figure 1)
              • ▪ Reasons for attending the EDS

              • ▪ Current dental registration status, and attendance

              • ▪ How people accessed the service

              • ▪ Knowledge of NHS Direct in accessing the EDS service, and satisfaction with accessing the service in this way

            • ◦ Section B (Figure 2)
              • ▪ Satisfaction with the service that they received on the day

              • ▪ Preference of location and how people want to access future OOH care.

            Section A of the questionnaire was completed before, and Section B after, seeing the dentist (Figures 1, 2). Questionnaires were collected in a labelled box at reception on each EDS site, supervised by the administrator and collected by the chief investigator. Demographic details were obtained from the Patient Information Management System. Data were analysed using SPSS for Windows software using parametric and non-parametric methods as appropriate to the corresponding response distributions. Initially, univariate comparisons of the two samples (over the two time periods) were undertaken using t-tests (or Mann-Whitney test) for continuous variables or chi-square tests (Pearson or chi-square test for trend) for categorical variables. Multiple regression was used to assess the differences in these outcomes between the two time periods, after adjusting for the effect of other covariates and possible interactions. The demographics-by-period interaction effects on those variables assessing change of attendance or attitude patterns were also explored.

            Results

            In total, 981 questionnaires were completed in the first time period (of which 73% were at King's) and 546 questionnaires were completed in the second (of which 79% were at King's). In line with ethics committee approval, patients who declined to participate in the study were not required to give reasons for this and therefore no data were collected on refusals. Overall during the two time periods a total of 2092 patients attended the service, giving an overall response rate of 75% (Table 1).
            Table 1

            Number of service users attending an out-of-hours emergency dental service over two time periods

             

            March 2006

            October 2006

            Total

             

            N

            %

            N

            %

            N

            %

            King's

            718

            73

            432

            79

            1150

            75

            Guy's

            263

            27

            114

            21

            377

            25

            Total

            981

             

            546

             

            1527

             
            There were no differences in gender, age or ethnicity of service users between the two time periods of the study (Table 2). Respondents who had used the service before were compared with those who had not and no differences by demographic details were found. However, there were differences in ethnicity across the sites with Guy's having 75% (n = 283) White and 18% (n = 68) Black service users, compared with 53% (n = 610) White and 33% (n = 380) Black service users at King's.
            Table 2

            Gender, ethnicity, age and payment status of service users attending an out-of-hours emergency dental service over two time periods

              

            March 2006

            October 2006

            Total

            P-values

              

            N

            %

            N

            %

            N

            %

             

            Gender

            male

            468

            51

            255

            49

            723

            50

            0.38

             

            female

            445

            49

            267

            51

            712

            50

             

            Ethnicity

            White

            520

            57

            306

            58

            826

            57

            0.79

             

            Black

            276

            30

            149

            28

            425

            29

             
             

            Others

            123

            13

            70

            13

            193

            13

             

            Age

            18–64 years

            857

            97

            491

            98

            1348

            97

             
             

            65+ years

            30

            3

            11

            2

            41

            3

             

            Normally pay for dental treatment?

            yes

            475

            52

            267

            52

            742

            52

            0.66

             

            no

            376

            41

            206

            40

            582

            41

             
             

            don't know

            58

            6

            39

            8

            97

            7

             

            Note: Question has multiple responses therefore total ≠ 100%

            Nature of dental problem

            Over both time periods, toothache was the main reason for attending the service (72%). There were no significant differences between the two time periods for the main reasons for attending (Table 3). In total, 90% of service users perceived their problem to be either 'urgent' or 'very urgent'.
            Table 3

            Reasons for attending amongst service users attending an out-of-hours emergency dental service over two time periods: Nature of dental problem

             

            March 2006

            October 2006

            Total

            P-Values

             

            N

            %

            N

            %

            N

            %

             

            Toothache

            660

            73

            370

            72

            1030

            72

            0.62

            Swollen face

            147

            16

            103

            20

            250

            18

            0.08

            Fractured filling/teeth

            151

            17

            93

            18

            244

            17

            0.52

            Loose or missing crown/bridge

            76

            8

            52

            10

            128

            9

            0.29

            To get advice on dental problem

            64

            7

            37

            7

            101

            7

            0.94

            Bleeding gums

            49

            5

            34

            7

            83

            6

            0.36

            Injury to mouth or jaw

            38

            4

            19

            4

            57

            4

            0.63

            Bleeding from mouth or face

            20

            2

            21

            4

            41

            3

            0.04

            Other reason

            5

            1

            2

            0

            7

            0

            0.99

            Note: Question has multiple responses therefore total ≠ 100%

            Reason for choice of service

            When asked why they were using this particular service, 42% reported that they were unable to be seen at another emergency dental service and 27% claimed that their dentist did not provide emergency dental care. 7% of respondents claimed that their dentist was no longer seeing NHS patients. There were significant differences for these reasons between the two time periods (Table 4). Whilst 28% of service users reported that an appointment was not available at their dentist in the first time period, this was lower at 20% in the second (P = 0.002) and in the second time period a significantly higher proportion of service users reported that the EDS was easier to get to than their own dentist (P = 0.003).
            Table 4

            Reasons for attending an out-of-hours emergency dental service over two time periods: Reason for choice of service

             

            March 2006

            October 2006

            Total

            P-Values

             

            N

            %

            N

            %

            N

            %

             

            Unable to be seen at other Emergency Dental Service

            303

            41

            170

            43

            473

            42

            0.6

            My dentist doesn't provide emergency care

            195

            26

            108

            27

            303

            27

            0.8

            Appointment not available at my dentist

            210

            28

            80

            20

            290

            25

            0.002

            Easier to get to than my dentist

            61

            8

            55

            14

            116

            10

            0.003

            My dentist no longer seeing NHS patients

            51

            7

            25

            6

            76

            7

            0.68

            Cheaper than going to my dentist

            12

            2

            7

            2

            19

            2

            0.87

            Visiting friends/relatives in area

            13

            2

            12

            3

            25

            2

            0.17

            For second opinion

            19

            3

            8

            2

            27

            2

            0.55

            For other reason

            10

            1

            10

            3

            20

            2

            0.16

            Note: Question has multiple responses therefore total ≠ 100%

            How service users were directed to the service

            The chief source of information about the service was from friends and family followed by NHS Direct. In the second time period, a significantly lower proportion had heard about the service from a dental receptionist (P = 0.002) (Table 5).
            Table 5

            How service users were directed to an out-of-hours emergency dental service over two time periods

             

            March 2006

            October 2006

            Total

            P-Values

             

            N

            %

            N

            %

            N

            %

             

            Family or friends

            246

            29

            159

            31

            405

            30

            0.62

            NHS Direct

            188

            22

            127

            24

            315

            23

            0.39

            Have used this service before

            131

            16

            78

            15

            209

            15

            0.77

            Dental receptionist

            119

            14

            45

            9

            164

            12

            0.002

            A & E

            78

            9

            42

            8

            120

            9

            0.44

            Dentist's answering machine

            54

            6

            22

            4

            76

            6

            0.09

            Doctor

            28

            3

            16

            3

            44

            3

            0.79

            Pharmacist

            8

            1

            3

            1

            11

            1

            0.45

            Primary care trust

            10

            1

            7

            1

            17

            1

            0.8

            South East London Doctors Co-op

            12

            1

            8

            2

            20

            1

            0.87

            Note: Question has multiple responses therefore total ≠ 100%

            NHS Direct

            In response to questioning about the awareness and use of NHS Direct, overall 35% of service users had used NHS Direct for advice about a health problem and 18% for advice about a dental problem. Although no differences were detected between the two time periods in terms of awareness, there was an increase in referrals attributed to NHS Direct (P = 0.02) and increased use of NHS Direct for dental problems, in the second time period (P = 0.002) (Table 6).
            Table 6

            Use of NHS Direct amongst service users attending an out-of-hours emergency dental service over two time periods

              

            March 2006

            October 2006

            Total

            P-values

              

            N

            %

            N

            %

            N

            %

             

            Aware of NHS Direct

            yes

            571

            64

            340

            67

            911

            65

            0.27

            Referred by NHS Direct

            yes

            147

            19

            109

            24

            256

            21

            0.02

            Ever used NHS Direct for health problem?

            yes – telephone and/or internet

            290

            35

            171

            36

            461

            35

            0.76

             

            no

            546

            65

            310

            64

            856

            65

             

            Ever used NHS Direct for dental problem?

            yes – telephone and/or internet

            142

            16

            115

            22

            257

            18

            0.002

             

            no

            771

            84

            398

            78

            1169

            82

             

            Note: Question has multiple responses therefore total ≠ 100%

            Last dental visit

            Overall the majority of service users reported visiting their dentist within the previous twenty-four months. In the first time period 80% reported that their last dental visit was at a dental practice whereas this figure was lower at 75% in the second; however, this difference was non significant (p = 0.08) (Table 7). Almost half of respondents (48%) reported attending a dentist less than every two years, with only 4% attending a dentist more than every six months (Table 8).
            Table 7

            Last dental visit amongst service users attending an out-of-hours emergency dental service over two time periods

              

            March 2006

            October 2006

            Total

            P-Values

              

            N

            %

            N

            %

            N

            %

             

            Last dental visit

            Over 2 years ago

            218

            25

            135

            29

            353

            27

            0.26

             

            13–24 months ago

            103

            12

            48

            10

            151

            11

             
             

            7–12 months ago

            139

            16

            76

            16

            215

            16

             
             

            6 months ago or less

            400

            47

            205

            44

            605

            46

             
             

            Never attended a dentist

            20

            2

            14

            3

            34

            2

             
             

            Trouble with teeth

            401

            43

            213

            43

            612

            43

             

            Reason

            Check up

            262

            28

            141

            29

            403

            28

            0.88

             

            Treatment

            241

            26

            126

            26

            367

            26

             
             

            Emergency dental service

            103

            12

            71

            16

            174

            13

             

            Location

            Dental practice

            679

            80

            342

            75

            1021

            79

            0.08

             

            Other

            63

            8

            43

            9

            106

            8

             

            Note: Question has multiple responses therefore total ≠ 100%

            Table 8

            Frequency of dental visits amongst service users attending an out-of-hours emergency dental service over two time periods

             

            March 2006

            October 2006

            Total

            P-Values

             

            N

            %

            N

            %

            N

            %

             

            Every 3 or more years/only when need to/never

            432

            49

            238

            50

            670

            48

            0.37

            Every 2 years

            51

            6

            33

            7

            84

            6

             

            Once a year

            138

            16

            85

            18

            223

            16

             

            Every 6 months

            221

            25

            103

            22

            324

            24

             

            More often than every 6 months

            41

            5

            20

            4

            61

            4

             

            Note: Question has multiple responses therefore total ≠ 100%

            Future emergency dental care

            With regard to how service users would like help for a future dental problem, the preferred choice was face-to-face with a dentist followed by telephone advice with an appointment the next day. The least preferred option was using the internet or digital TV. There were significantly higher proportions of service users preferring face-to-face contact with a dentist and a significantly lower proportion preferring phone advice (p = 0.02) followed by a next day appointment at their own dentist in the second time period(P = 0.03) (Table 9).
            Table 9

            Future preferences for accessing emergency dental care amongst service users attending an out-of-hours emergency dental service over two time Periods

              

            March 2006

            October 2006

            Total

            P-values

              

            N

            %

            N

            %

            N

            %

             

            How would like to get help – face to face with dentist

            1: Most Desirable

            380

            78

            270

            82

            650

            79

            0.02

             

            2

            33

            7

            27

            8

            60

            7

             
             

            3

            29

            6

            18

            5

            47

            6

             
             

            4

            11

            2

            1

            0

            12

            1

             
             

            5: Least desirable

            37

            8

            14

            4

            51

            6

             

            How would like to get help – phone advice with own dentist next day appt

            1: Most Desirable

            348

            66

            168

            55

            516

            62

            0.03

             

            2

            98

            18

            70

            23

            168

            20

             
             

            3

            44

            8

            43

            14

            87

            10

             
             

            4

            12

            2

            10

            3

            22

            3

             
             

            5: Least desirable

            29

            5

            15

            5

            44

            5

             

            How would like to get help – phone advice with local dentist next day appt

            1: Most Desirable

            188

            44

            89

            34

            277

            40

            0.13

             

            2

            117

            27

            85

            32

            202

            29

             
             

            3

            69

            16

            51

            19

            120

            17

             
             

            4

            21

            5

            20

            8

            41

            6

             
             

            5: Least desirable

            34

            8

            17

            6

            51

            7

             

            How would like to get help – phone advice from dentist

            1: Most Desirable

            188

            41

            86

            32

            274

            37

            0.1

             

            2

            109

            23

            62

            23

            171

            23

             
             

            3

            71

            15

            69

            25

            140

            19

             
             

            4

            51

            11

            33

            12

            84

            11

             
             

            5: Least desirable

            45

            10

            22

            8

            67

            9

             

            How would like to get help – phone advice from nurse

            1: Most Desirable

            98

            23

            36

            14

            134

            20

            0.06

             

            2

            92

            22

            46

            18

            138

            20

             
             

            3

            89

            21

            81

            31

            170

            25

             
             

            4

            72

            17

            57

            22

            129

            19

             
             

            5: Least desirable

            77

            18

            38

            15

            115

            17

             

            How would like to get help – internet/digital TV

            1: Most Desirable

            77

            18

            26

            10

            103

            15

            0.06

             

            2

            54

            13

            33

            13

            87

            13

             
             

            3

            75

            17

            52

            20

            127

            18

             
             

            4

            42

            10

            35

            13

            77

            11

             
             

            5: Least desirable

            183

            42

            115

            44

            298

            43

             

            Note: Question has multiple responses therefore total ≠ 100%

            With regard to what time of the day people would like to attend for emergency dental care, the preferred choice both before and after the introduction of the new contract was early morning. The responses in order of preference were: early morning (75%), evening (61%), weekends (53%) and lunchtime (29%). Significantly greater proportions of service users in the second survey (after the introduction of the 2006 dental contract) indicated a preference to attend in the evenings (p = 0.0001) and at a weekend (p = 0.02) (Table 10).
            Table 10

            Future preferences for timing of emergency dental care amongst service users attending an out-of-hours emergency dental service over two time periods

              

            March 2006

            October 2006

            Total

            P-values

              

            N

            %

            N

            %

            N

            %

             

            Prefer to attend early morning

            1: Most desirable

            447

            77

            211

            72

            658

            75

            0.21

             

            2

            47

            8

            27

            9

            74

            8

             
             

            3

            28

            5

            18

            6

            46

            5

             
             

            4

            14

            2

            10

            3

            24

            3

             
             

            5: Least desirable

            46

            8

            26

            9

            72

            8

             

            Prefer to attend evening

            1: Most desirable

            235

            56

            197

            69

            432

            61

            0.0001

             

            2

            55

            13

            28

            10

            83

            12

             
             

            3

            64

            15

            35

            12

            99

            14

             
             

            4

            27

            6

            12

            4

            39

            5

             
             

            5: Least desirable

            42

            10

            15

            5

            57

            8

             

            Prefer to attend weekend

            1: Most desirable

            165

            49

            126

            59

            291

            53

            0.02

             

            2

            49

            15

            25

            12

            74

            13

             
             

            3

            34

            10

            26

            12

            60

            11

             
             

            4

            29

            9

            18

            8

            47

            9

             
             

            5: Least desirable

            57

            17

            20

            9

            77

            14

             

            Prefer to attend lunchtime

            1: Most desirable

            87

            27

            62

            32

            149

            29

            0.5

             

            2

            109

            34

            41

            21

            150

            29

             
             

            3

            46

            14

            39

            20

            85

            17

             
             

            4

            27

            8

            10

            5

            37

            7

             
             

            5: Least desirable

            53

            16

            41

            21

            94

            18

             

            Note: Question has multiple responses therefore total ≠ 100%

            Satisfaction with the service

            Overall 95% of service users were satisfied with the out-of-hours service; however, issues were raised around unmet expectations of an emergency dental service and a lack of information about treatment and charges available. There were no significant differences between the two time periods.

            Improving the service

            The service users were asked whether they had any further comments on how the service could be improved. Improving staff numbers and extending opening hours were the most common suggestions. Other areas for improvement included shorter waiting times, better facilities, better treatment options and improved information on the website.

            Discussion

            The introduction of a new national NHS dental contract in 1992 provoked a number of studies during the 1990s about attendance patterns [1115], which highlighted the increasing demand for emergency dental services. Subsequently, research focussed on ways of managing demand and improving access [8, 9] including a move to use of telephone triage. However, by 2000 research highlighted wide variation in the provision of services and suggested that increased use of services such as NHS Direct may help to reduce inequity of access [16]. Further qualitative research examined expectations of and satisfaction with emergency dental services in order to further understand some of the reasons how and why people access out-of-hours emergency dental services [3, 4, 6, 7, 10].

            Service users numbers and personal characteristics

            This study had a good response rate of over 70% and the differing response sizes (with King's providing 75% of the service users) are explained by the differing size of service provision at the two geographic sites. The differences in geographic location could explain the varying ethnicity of service users, with unpublished hospital attendance data showing that around 72% of service users at Guy's were people from outside the immediate boroughs such as commuters, reflecting its proximity to a mainline railway station, whereas 69% of service users at King's are from the local boroughs, whose population is characterised by a socially deprived, ethnically diverse and mobile population.

            Nature of dental problem

            Overall, the majority of service users were attending with the same pattern of problems (toothache, swollen face and fractured tooth/filling) over the two time periods, suggesting that six months into the new contract there was little change in the reasons for attending the service. This pattern of service use was similar to findings in previous studies of attendance at an emergency dental service [4].

            Patterns of service use

            There was little evidence of change in the major influences determining the patterns of service use; however, the results of this study suggest that after the introduction of the 2006 dental contract fewer service users were likely to report that their own dentist would not see them or that they had been referred on by a receptionist. The popular perception at the time was of difficulty in accessing a dentist, heightened by negative media coverage. This may have dissuaded emergency patients from attempting to get an appointment directly with the dentist resulting in them going direct to the EDS or via NHS direct, which made significantly more referrals. Alternatively, primary dental care may have been more able to absorb emergency patients, resulting in less referral on from providers to the EDS. Either way this fits with the overall trend of reducing primary dental care uptake following the introduction of the new contract.

            NHS Direct

            After the introduction of the 2006 dental contract more service users were being referred to the service by NHS Direct and more service users were using NHS Direct for advice about a dental problem. This suggests increasing awareness and use of NHS Direct for dental problems and is in line with national policy around future commissioning of out-of-hours care using telephone triage systems to prioritise according to need. The increasing use of NHS Direct may also reflect either real or perceived problems that service users had with accessing a general dental service. Studies of general medical practice have shown that use of NHS Direct may limit demand for out-of-hours care [17, 18], and the experience of NHS Direct itself is that a high percentage of callers can be successfully managed by telephone advice followed by an appointment with a local dentist during normal working hours.

            Limitations and benefits of the study

            As already noted, the study was carried out against a period of major policy change in the provision of primary dental care during which widespread negative media coverage focussed on the difficulties in accessing an NHS dentist for routine dental care [2]. The interval between studies was six months, which although long enough for service evaluation and to inform local commissioning, may not have been sufficiently long enough to evaluate the effect of a policy change as service users may not have been aware of a change in primary dental care provision; this may be the reason for the similar patterns of service use before and after the introduction of the new dental contract.

            The study design was a two-stage cross-sectional survey. Therefore the respondents constitute different service users at different time points, without a control group. This is a potential source of bias, however there were no significant differences found in the personal characteristics of the respondents at the two time periods, which strengthens the internal validity of the study.

            Recognising the above limitations and the fact that this was a study of an emergency dental service provided within the locality of a dental teaching hospital in inner-city London, the findings will therefore be useful for any other organisation developing new models of out-of-hours care for emergency dental services by providing valuable information on how and why people access these services.

            Implications for commissioning, policy and research

            There is increasing public expectation around provision of care outside normal working hours and in line with these trends, the Department of Health is reforming the pattern of delivery of care for it to fit better around people's busy lives [19]. However, if a significant proportion of the population is accessing an out-of-hours emergency service for convenience due to the relative ease of access of this type of service, then there may need to be a method of triaging cases to allow those who need urgent care to access it appropriately [20]. The Department of Health recommendations for commissioning out-of-hours services include the use of dental triage systems in either open or closed door systems in order to prioritise according to need [1].

            Following this study, local commissioning organisations have made major changes in the provision of emergency dental services, which are now accessed via telephone triage. Patients needing urgent care receive a same day appointment with less urgent cases referred directly from telephone triage to dental practices. Dental contracts have been revised to reflect these changes, which include extending opening hours and also allowed for the creation of open access slots during the working day. These appointment slots during normal working hours are kept free for emergency patients who either contact the practice directly or who are referred via the telephone triage service. As patient satisfaction with the direct access service was generally positive, further research is needed on evaluating outcomes of new models of emergency care, following changes in service provision.

            This study has also highlighted the importance of friends and family in providing knowledge about out-of-hours emergency dental care, despite the increasing awareness and use of NHS Direct. In light of the importance of informal networks of knowledge, commissioners should therefore consider strategies for communicating health service information to the public on accessing these important services.

            Conclusion

            This study has provided an insight into how and why people use an out-of-hours emergency dental service and has helped to guide commissioning of emergency dental services in south-east London. Despite a major change in the contractual arrangements for the provision of primary dental care, users continued to access emergency care in much the same way except for some minor changes in line with wider trends, such as more use of NHS Direct and a preference for future emergency dental care at the evenings and weekends. Informal information networks such as friends and family remain an important source of information about accessing emergency dental services. In line with these trends, NHS organisations will need to consider how to commission services in future, an important element of which should be a strategy to communicate information about the service to the public.

            Declarations

            Acknowledgements

            We would like to thank the Clinical Directors and staff working in the Emergency Dental Services of both hospitals, Lambeth, Southwark and Lewisham PCTs, Pav Garcha formerly at King's Dental Institute, who supported this study in the planning stage and Derek Cooper, Statistician who assisted with data input and statistical support.

            Authors’ Affiliations

            (1)
            Department of Oral Health Services Research and Dental Public Health, Kings College London Dental Institute
            (2)
            NHS Southwark Primary Care Trust
            (3)
            NHS Lewisham Primary Care Trust
            (4)
            Unit of Biostatistics, King's College London Dental Institute
            (5)
            NHS Lambeth Primary Care Trust

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            21. Pre-publication history

              1. The pre-publication history for this paper can be accessed here:http://​www.​biomedcentral.​com/​1472-6831/​9/​19/​prepub

            Copyright

            © Austin et al. 2009

            This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.