Prioritising limited resources in a high-caries practice population
You have recently taken over clinical leadership of a four-surgery practice in a deprived urban ward. The contract is 24,000 UDAs a year with four dentists, two therapists and one hygienist. Of roughly 3,000 registered children, only 55% attended in the last 12 months. Local survey data for five-year-olds give a mean d3mft of 3.1, with 42% having untreated decay, against a national mean of 0.8. Adult attendance is high but the practice is running at 104% of contract with a clawback risk, and the dentists report being fully booked with urgent care. The therapists have spare capacity in their diaries. The commissioner is offering a small additional payment for a supervised toothbrushing scheme in local nurseries but no extra UDA funding for children's prevention.
1. Where would you target effort in the first six months, and why?
Read the worked answer
Target the children who are not attending, using the staff group with spare capacity - not more of the same urgent adult care.
Reasoning:
- The need is concentrated: 42% untreated decay and a mean d3mft of 3.1 in five-year-olds means a large proportion of disease is untreated, and 45% of registered children have not been seen for a year. The gap is access and prevention, not clinical skill.
- Therapists are the underused resource. Redirecting their diary to child prevention and treatment is the only lever that adds capacity without breaching the contract further.
- Urgent adult care is a symptom - it must be managed (triage, skill-mix) but it will not reduce future need; only prevention will.
Practical first moves:
- Recall and risk-stratify children rather than blanket recalls; call/recall the 45% non-attenders, using text and phone, with appointments in after-school and school-holiday slots.
- Use therapists for child assessment, fluoride varnish, sealants and simple restorations, with dentist oversight of complex cases.
- Adopt the nursery toothbrushing scheme - it is low-cost, reaches children who never attend, and is a route to registration; the small payment plus the access benefit justifies it.
- Audit the baseline (d3mft of your own child population, varnish coverage) so any improvement can be demonstrated.
2. Set out the preventive protocol you would standardise for children in this practice, with intervals and products.
Read the worked answer
Standardised, risk-based child prevention (adapt to national guidance and local formulary):
- Risk assessment at every visit - caries, diet, fluoride exposure, plaque, medical/social factors, plus attendance history. Risk determines interval, not habit.
- Recall interval: low risk 12 months; high risk 3 months, with a documented reason for any interval outside 3–12 months.
- Fluoride varnish: twice yearly for all children from age 2 (from first tooth eruption in high-risk children), applied by therapist or dentist; four times yearly for high-risk children.
- Toothpaste: age-appropriate fluoride concentration - 1,000 ppm smear 0–2; 1,350–1,500 ppm 3–6; from 7 years 1,350–1,500 ppm, escalating to 2,800 ppm for children at high caries risk (age 10+ per guidance). Supervise brushing, spit don't rinse.
- Fissure sealants on erupted permanent molars in high-risk children.
- Diet: specific, actionable advice - free-sugar exposure limited to mealtimes, no sugary drinks in bottles or at bedtime; avoid vague 'cut down on sugar' messages.
- Silver diamine fluoride or Hall technique where conventional care is not tolerated, rather than extraction or general anaesthetic referral as a first resort.
- Staff training and a written protocol so care does not depend on which clinician the child sees; audit varnish and sealant uptake quarterly.
3. The dentists object that prevention 'doesn't earn UDAs'. How do you reconcile the contract pressure with the prevention plan without compromising care?
Read the worked answer
Be honest: there is a real tension, and the answer is skill-mix plus explicit prioritisation, not fudging the contract.
- Quantify the problem - audit where the 104% activity is coming from. Urgent, repeated, low-value appointments often consume disproportionate UDAs; a short internal audit usually shows unwarranted variation in recall intervals and in who does what.
- Move work down the skill mix where it is safe and remunerated: therapists doing child examinations, varnish, sealants and simple restorations frees dentist time for the complex care that genuinely requires it. Check the contract rules for what therapists can claim.
- Right-size adult recall - low-risk adults on 12-month recalls free capacity without reducing quality; this is a within-contract change, not a cut.
- Treat the nursery scheme as a separate funding stream and protect that time rather than absorbing it into UDA-earning sessions.
- Escalate honestly to the commissioner with data: if the contract currency does not pay for prevention, say so with the local child caries figures, and propose a prevention-focused pilot. Do not silently drop prevention to hit a target - under-treating children to protect the contract is not a defensible trade.
- Protect the non-negotiable minimum regardless of contract: urgent care for pain, safeguarding, and a documented prevention offer at every child visit. If the contract genuinely cannot fund that, it must be recorded and raised, not concealed.