Dentists’ Working Patterns, Motivation and Morale - 2018/19 and 2019/20 Methodology

The analysis is based on a sample determined by those dentists who completed the Dental Working Patterns (DWP) Survey. Each survey, which runs biennially, covers two distinct financial years. The results are weighted to reflect the nature of the working population, which is derived from data sets provided by:

1. 1. NHS Business Service Authority (BSA), Information Services for dentists in England and Wales. The population consists of Providing-Performer and Associate primary care dentists working on General Dental Services (GDS) and/or Personal Dental Services (PDS) contracts. To be included in the population, dentists must have at least one Unit of Dental Activity (UDA) or Unit of Orthodontic Activity (UOA) recorded against them on an FP17[1] form, for one or both of the financial years covered by the survey.

1. 2. NHS National Services, Scotland, Information Services Division (ISD) for dentists in Scotland. The population consists of Principal and Associate primary care dentists and to be included dentists must have at least one paid Course of Treatment of (NHS) dental activity recorded against them for one or both of the financial years covered by the survey.
   3. Northern Ireland Business Services Organisation (BSO) for dentists in Northern Ireland. The population consists of Principal and Associate primary care dentists and in order to be included dentists must have at least one ‘Item of Service’ of (Health Service) dental activity recorded against them for one or both of the financial years covered by the survey.

England and Wales

Under the contractual arrangements introduced on 1 April 2006 in England and Wales, contract holders are termed ‘providers’ and those performing dental treatments or activities are termed ‘performers’. NHS England/Local Health Bodies (LHB) have a contract with providers who deliver an agreed level of dental services. A provider who sub-contracts all the dental activity under their primary contract is termed a Provider Only and these dentists have been excluded from the analysis in this report. A provider who also performs some dental activity under their contract is referred to in the report as a Providing-Performer. A dentist who performs dental activity under a dental contract, but does not hold that contract, is termed an Associate.

Primary Care Dentists operate under one or more contractual arrangements in England and Wales: General Dental Services (GDS); Personal Dental Services (PDS); and community/salaried dental services (formally Trust-led Dental Services). Dentists who work on both GDS and PDS contracts are referred to as ‘mixed GDS/PDS’. Those dentists working solely under a community/salaried service contract have been excluded from this report because they are not classed as self-employed primary care dentists; however, those GDS and/or PDS dentists also working under a salaried/community service contract have been included.

When the contractual arrangements came into force on 1 April 2006, many of the PDS contracts between dental practitioners and Primary Care Trusts/LHBs were time-limited, with a maximum duration of three years. In anticipation that these contracts would expire, some dentists are known to have exercised their statutory right to have their PDS contracts terminated, and be issued with GDS contracts, which are not time limited. This will have contributed to the reduction of the all-dentist PDS population, as shown in Annex B.

For the first time, findings from the Dental Working Patterns Survey are presented separately for England and Wales. In previous reports, results were calculated and presented for England and Wales together. Details of the impact of this change are explained in the Methodological Change Notice and described in the following sections.

Northern Ireland

The results in the report are presented by dental type classification, with their descriptions provided in Table A1.

Table A1: Summary of dental type classifications included in Dental Working Hours, Northern Ireland, 2018/19 and 2019/20

As dentists in Northern Ireland operate under one type of contract, results are presented only for General Dental Services (GDS) dentists.

Scotland

The results in the report are presented by dental type classification, with their descriptions provided in Table A2.

Table A2: Summary of dental type classifications included in Dental Working Hours, Scotland, 2018/19 and 2019/20

As dentists in Scotland operate under one type of contract, results are presented only for General Dental Services (GDS) dentists.

England

To weight the sample results to reflect the nature of the NHS BSA Information Services population, dentists were allocated to one of 16 strata defined using the variables shown in table A3. This is consistent with the stratification of the 2018/19 Dental Earning and Expenses Estimates Methodology[1] and onwards. However, this marks a change from preceding years (2017/18 and earlier) when contract type (i.e. GDS, PDS and mixed) was also included in the stratification. As discussed the separation of the analysis for England and Wales and the gradual reduction in PDS contracts, means that it is no longer viable to include contract type in the stratification due to the low sample size of some of the strata.

Table A3: Stratification variables, England

^{Note: Please see England and Wales section above for a further explanation of dental type}

Northern Ireland, Scotland, and Wales

Dentists have been allocated to one of six strata, defined using the variables shown in table A4. These six strata were used to weight the sample results to reflect the nature of the BSO, ISD and NHS BSA populations. This is consistent with the stratification of the Dental Earnings and Expenses, 2018/19² methodology.

Table A4: Stratification categories, Northern Ireland, Scotland and Wales

Whilst dental type is an important determinant of dental working patterns, it was not possible to use this variable for stratification purposes in Scotland and Northern Ireland because the information is not held at population level in these countries. In this case, the only way to determine Principal and Associate dentists is from the survey responses, which means this variable was limited to the sample that returned the survey. As a result, the population of Principal and Associate dentists shown in the report was estimated from the entire population using the proportion of these dentists found in the survey. This population count will not match other sources, particularly the Dental Earnings and Expenses Estimates, 2018/19 as different methodologies are used to determine population counts. The official workforce figures for GDS dentistry in Scotland are provided by ISD (found at: www.isdscotland.org) and by BSO in Northern Ireland.

Whilst dental type is held at the population level for Wales, the relatively low population of dentists in this country means stratification including dental type would result in a low sample size in some of the strata (12 in total) and it was therefore decided to match stratification in Wales with Northern Ireland and Scotland so that all the methodologies align.

Since the introduction of the Dentists Act 1984 (Amendment) Order 2005 (SI 2005/2011), it has been possible for dentists to incorporate their practices and operate as a limited company. It is currently not known how many dentists have incorporated, and the precise effects this may have on the results presented in the report. However, some possible effects are discussed in more detail in paragraphs A18 of this Annex. In addition, further information of this issue is discussed in the Dental Earnings and Expenses Estimates, 2018/19[2] report.

Unlike the situation in Scotland and Northern Ireland, the dental type classification used in this report for England and Wales is provided by NHS BSA data. However, all dentists who respond to the DWP Survey are also asked for their NHS working arrangements, notably their dental type, with Providing-Performer dentists being asked additional questions about their business arrangements. This means that the dental type declared by survey responders can be compared to that provided by NHS BSA. Over 5,000 dentists in England and Wales returned a valid survey response (as described in Annex C) and just over 500 had a discrepancy in their dental type classification. The results from 2016/17 to 2019/20 are shown in tables A5 and A6.

Please note, for 2018/19 and 2019/20 there has been a change in the methodology to identify dental type in England and Wales based on data sent from NHS BSA. This change is discussed in more detail in the Methodology Change Notice.

Table A5: Providing-Performer, level of agreement between NHS BSA and DWP Survey dental type, England and Wales, 2016/17 to 2019/20

Table A6: Associate, level of agreement between NHS BSA and DWP Survey dental type, England and Wales, 2016/17 to 2019/20

Both tables show that compared to 2016/17 and 2017/18, there have been improvements in the levels of agreement for the last two years, which is a direct result of the change in methodology to determine dental type. Whilst the level of agreement was typically stronger for Providing-Performer dentists using the old methodology, the fact that some practice owners were incorrectly identified as Associate dentists meant the level of agreement for Associates was much lower, however, this how now shown a clear improvement.

One explanation for the discrepancy is that, like the old methodology, the new methodology still misses some incorporated businesses. Whilst this provides a possible explanation for the discrepancy, there may be other reasons as well. Please refer to the Dental Earnings and Expenses Estimates, 2017/18[1] publication for further information on incorporation.

Calculations based on survey data

The full-year population figures shown in the result chapters and Annex B are estimates based on the number of ‘full-year’ dentists found in the survey (i.e. those dentists who indicated they worked for a full year, regardless of annual leave). Total figures may not sum due to rounding. Final NHS/private share and clinical/non-clinical percentages are calculated in different ways depending upon the section they appear in:

1. Dental Working Patterns (i.e. weekly hours, annual leave, NHS and clinical share) - by multiplying individual NHS share and clinical work (%) of each dentist by their total weekly hours so that the final weighted average figures are representative of the total work of the population.
2. Motivation Results – weighted average figures based purely on individual figures for each dentist.

Results based on total NHS weekly hours are determined by multiplying the weekly hours of each dentist by their proportion of NHS dentistry.

Error bars displaying 95% confidence intervals have been used in some of the motivation chapters, supporting measurement of statistical significance at the 5% level. The error bars are defined as 1.96 x standard error of the mean and assume normal distribution of weekly hours and annual leave for the samples. These confidence intervals aid interpretation of the results to show if there is meaningful change between one cohort and another.

The Dental Working Patterns (DWP) survey was first run in January 2008 and considered the working patterns of dentists in England and Wales for 2006/07 and 2007/08. Since then the survey has been extended to include dentists in Scotland and Northern Ireland and has been undertaken every two years. Differences between the 2018/19 and 2019/20 survey and previous iterations are summarised below.

2006/07 and 2007/08

In the NHS Business and Provider and Performer Arrangement section, the 2006/07 and 2007/08 survey did not specifically ask for data related to primary care dentistry, whereas subsequent surveys do. It is, therefore, possible that the 2006/07 and 2007/08 report contained some secondary care dentistry in the results.

The 2006/07 and 2007/08 survey asked how time devoted to dentistry was split between clinical and administrative work. This question was changed for the 2008/09 and 2009/10 and subsequent surveys to ask how time was split between clinical and non-clinical work, noting that the latter may include administration and management duties. This aimed to ensure that all time spent on dentistry was included. This difference may affect the way that dentists answered the question for the two surveys. Other questions in later surveys were slightly reworded to try and make them as clear as possible[1].

2008/09 and 2009/10

Both the working and business arrangement questions following the 2008/09 and 2009/10 survey were altered. Each question had an additional option to enable further identification of those dentists who have incorporated their business: in the working arrangement question, a new option entitled ‘Associate – Incorporated’ was added and in the business arrangement question, the ‘Partnership’ option was divided into ‘Limited Liability Partnership’ and ‘’True’ Partnership’, with the former representing the incorporated option of a business held as a partnership[2].

The number of Associate dentists that indicated they were ‘Associate – Incorporated’ was low (about 6% of all dentists) and, as a result, they were left in the Associate cohort for the analysis in this and earlier reports. The main reason for their ongoing inclusion was that the analysis in years before 2010/11 and 2011/12 included Associates who had incorporated their business and their retention has allowed the time series to be unbroken.

2010/11 and 2011/12

The survey was collected online from 2012 onwards rather than by a postal return, as used in earlier surveys. There was a decrease in the overall return rate, the size and effect of which is discussed in more detail in Annex C.

2012/13 and 2013/14

The last four DWP surveys (covering 2012/13 to 2019/20) have included seven questions on motivation and one on morale. Please see Annex A in the main report for a copy of the latest survey and the additional questions. Whilst none of the other workload and arrangement questions were altered from the 2010/11 and 2011/12 survey onwards, the inclusion of the motivation and morale questions might have affected how dentists answered the other questions.

2014/15 and 2015/16

For the last three DWP surveys (covering 2014/15 to 2019/20) dentists in England were sent only an invitational email and not an accompanying letter; dentists in Wales, Scotland and Northern Ireland received both. The survey response rate in England has decreased for the two most recent surveys and is discussed in more detail in Annex C.

The motivation and morale of dentists has been decreasing since these attributes were first measured in the 2012/13 and 2013/14 DWP Survey. As a result, it was agreed at the Dental Working Group (DWG) that the 2016/17 and 2017/18 survey should have an additional question on the potential causes of low morale. More information about the development of this question is included in Annex D. This question was included at the end of the survey after all the other questions had been addressed but it is possible that its inclusion may have affected dentists’ responses.

2016/17 and 2017/18

Between the 2012/13 and 2013/14 and the 2016/17 and 2017/18 surveys, questions three and eleven, and questions four and twelve, which ask respondents to estimate the amount of time they spend on clinical activity and NHS/Health Service work respectively, used an on-screen slider for users to select values. Respondents using mobile devices found it difficult to use the slider, suggesting it was an inaccurate means of data collection. As a result, the sliders were replaced by data entry boxes in the last survey.

Summary

It is difficult to predict the effect these differences could have had on how survey questions were answered but they should be borne in mind when considering the results.