We explore how this was made possible, and why it is so important to have a sustainable remuneration model for the future of dentistry.
Since becoming an Educational Supervisor (ES) in 2018, I have been aware of concerns that dental students are graduating with a reduction in clinical experience. This creates challenges during Dental Foundation Training (DFT) where practices struggle to marry up substantial educational needs with practice finances due to the long-standing Item of Service (IoS) model of remuneration for ESs in Northern Ireland.
Although we work under the same Educational Contract as England and Wales, the model of DFT payment is different. As part of COVID-19 emergency arrangements, we moved temporarily to a block grant payment model which refocuses DFT with FD educational needs placed first. As applications reopened for training year 22/23, we did not know how remuneration was going to work, leaving many of us wondering if training would be a viable option if it returned to IoS payments, based on FD activity.
How does dental training work?
Before the pandemic, FDs had a minimal practice induction with an expectation to increase activity quickly, which was an intense learning curve. This wasn’t in the FDs’ best interests, with educational needs pressured by the need to increase activity. The impact of COVID-19 restrictions on undergraduate experience meant that an IoS model was not viable. Northern Ireland Medical and Dental Trainee Agency (NIMDTA) now implement an extended induction where trainees carry out phantom head exercises, complete audits, and get used to administrative procedures. There are also patient-based assessments that need to be completed to identify learning needs and tailor the appointment book accordingly. It allows a more effective introduction to practice life and reduces stress during the transition.
Gradually, FDs start seeing patients independently, but this takes months of careful appointment scheduling until they can manage increasing volumes of patients. I carry out weekly ADEPT (clinical procedures) and Case Based Discussion assessments, along with a minimum of 40 tutorials, and help throughout the working day where the FD needs my opinion or help with a patient. We also complete an e-portfolio which documents the training journey and is an opportunity for reflection and feedback. The FD must also prepare three Case Presentations throughout the year which are anonymously assessed by FDs, ESs and Advisors within the scheme.
FDs are responsible for their own patient list to provide dental care and gain increased confidence and competence in the many aspects of general practice. Most graduates are trained in evidence-based dentistry, many within a Dental Hospital environment, but challenges arise when they enter a predominately Health Service training programme where economics come into play, with restrictions on materials such as composites to anterior teeth. Everything is new to our trainees, and the Department perhaps does not always realise that.
At university, in an hour and a half, they may do one filling with the guiding hand of a supervisor giving them time and space to learn. Realistically in practice, 30 minutes would be expected. Check-ups that take us 15 minutes, could take a trainee an hour in the early weeks. To give FDs the best possible start in practice, I block out my book to provide one-to-one teaching, which means that my own income is affected. In this training scenario, under the IoS system, that means that the first few days of induction show minimal activity, even though the FD and the ES are working. Even after induction, activity levels may continue to be low depending on the ability of the FD. If the practice is being paid for activity carried out, it simply does not add up.
Block grant supports effective dental training
COVID-19 meant that FDs graduated with significant gaps in clinical experience, requiring more support from ESs than previous cohorts. Ongoing restrictions also resulted in reduced volumes of appointments being available to gain experience. Graduates leaving university now have still had their clinical years impacted by the pandemic, and alongside this we are receiving a greater number of overseas graduates with different challenges.
Although the block grant is not perfect, we need to retain it for the sake of our FDs.
Many of our overseas graduates required extended inductions and were not able to start in their training practices in time while waiting on GDC numbers and paperwork. Some needed extra training in amalgam, endodontics, or IRMER-compliant radiography. We want to ensure we can put the educational needs of all our FDs first with practices not financially disadvantaged by ensuring educational quality. The block grant whilst not ensuring financial viability, does provide stability, predictability and makes DFT more equitable for training practices. That is why we felt the block grant needed to continue.
NIMDTA were in support of retaining the block grant model but there was still work to be done to secure it from the Department. After contacting the BDA, I received support with the next steps. Firstly, we needed evidence, so I carried out a qualitative survey among ESs. The overwhelming response showed that although the block grant is not perfect, we need to retain it for the sake of our FDs.
Armed with the evidence, a letter to the DoH regarding the block grant was drafted that was co-signed by the majority of ESs, the co-chair of the Northern Ireland Dental Practice Committee Ciara Gallagher, and the BDA, making a compelling case for the block grant model. The BDA also ensured that it went to the right contacts and kept it on their agenda. Approval of retention of the block grant model by the Permanent Secretary was confirmed on 9 August 2023, and this represents a great success for DFT and the BDA.
Hopes for the future of dental training
In the current financial climate, practices need to be assured that DFT will not impact practice economics. I love training, and our ESs that return year after year do not do it for money. We do it because we genuinely enjoy mentoring recent graduates and feel it keeps the practice young, aware of new trends, and professionally enhances our day-to-day work.
Mentoring is so rewarding, and I would like to make that experience as good as possible for our future dentists and keep them in the industry. We have a retention crisis, and a positive DFT year can really help to shape the career of a young dentist.
In the future, I would like to see a regular, ongoing review process put into place for remuneration. Practices sometimes feel penalised for FDs that need more help, with the effect that has on activity. To combat this, I believe the remuneration model should focus on educational targets, quality standards, and the needs of the FD, with realistic and achievable service delivery.
There should be incentives to reward practices with outstanding trainees who are doing good work for the Health Service. We need to build a model that recognises the importance of DFT in terms of valuing the dedication of ESs and training practices alongside the needs of FDs in this critical stage of professional development. In the future I will be hoping for more collaborative working, and more listening to the profession to make positive changes that take our concerns on board.