In these uncertain times, dental practices would do well to ensure their stability and future success by considering how to strengthen their business and one way of doing so is to consider the potential of dental referrals.
This perhaps underrated part of dentistry’s operations can help boost patient numbers as well as help patients get the help they need and better care.
Referrals are built into the system. All dentists have to comply with the General Dental Council’s (GDC) Scope of Practice rules1 which set out the skills and abilities each registrant group should have. Dentists should only carry out a task or type of treatment or make decisions about a patient’s care if they are sure that they have the necessary skills and are appropriately trained, competent and indemnified.
In other words – if a task, type of treatment or decision is outside the clinician’s scope of practice or they do not feel they are trained nor competent to do it, they must refer the patient to an appropriately trained colleague.
Doing so involves explaining clearly to the patient the reason for the referral and getting their consent after hearing the dentist’s diagnosis and treatment options.
In addition, the NHS commissions a dedicated referral management service – Dental Referrals – to ensure patients are seen in the most appropriate settings for their care needs.
Under the system, a patient’s referral is assessed by a clinician who determines, from the information provided by a dentist, where this is whether that be in a hospital or in a community or primary care setting.
One way of boosting referrals to a practice is to make sure that existing patients are happy with their treatment and experience. A happy patient is far more likely to spread the word to their friends and family about their positive experience which could bring new patients to the practice.
Referrals are important as British Dental Association (BDA) chair Mick Armstrong says: “Offering referrals to specialists expands the range of services a practice can offer to patients who need or demand complex dentistry.
“It retains patients and often family patients within the referring practice and supports lesser experienced less confident practitioners.
“Accepting specialist referrals grows the business and generally provides more interesting and rewarding careers for those wanting to improve their skills and reputation and experience.”
There have been concerns for some time about a shortage of dental specialists to whom referrals can be made. A recent article 2 in BDJ In Practice said: “There are vast swathes of the UK with little to no access to specialists, rendering services to patients as no more than a postcode lottery - treatment is therefore provided by availability, not need.”
With children’s oral health, for example, in 2000, when the specialist list for paediatric dentistry was established, there were initially around 200 specialists registered in the United Kingdom, and by 2008, there were 234 and the numbers today are similar at 239. This is contrast to the 1,400 registered specialists in orthodontics. Such a shortage of paediatric specialists has had an impact and is thought to have contributed to the fact that decay is the main reason for children to be admitted to hospital.
Nevertheless, specialists are making the best of it and have an optimistic outlook.
Dr James Davies, specialist orthodontist and principal owner of Quayside Orthodontics in Carmarthen, Wales, which treats NHS and private patients, says the practice which is spread over two sites, receives around 200 referrals a year for private patients and another 800 from the NHS.
“Referral numbers have risen in the past few years because people are more aware of their teeth and the aesthetics so there is a greater demand from the patients,” he says. “Older people as well realise it’s not too late to get their teeth straightened.
“From the NHS point of view, numbers are increasing because all the kids want it. It’s a trendy, fashionable thing to wear a brace now.” The benefits of referrals are clear, he argues, saying: “There are dental health benefits in the respect that it’s easier to keep straight teeth clean as opposed to crooked teeth and your self-esteem and self-confidence is massively increased.”
Patients often like to have choices too, as he adds: “We live in a litigious world and if you haven’t offered it to a patient, they might turn around one day and say why didn’t you send me to a specialist? You need to give them a thorough examination and give them their options.”
The practice was helped earlier this year by the Green Apple Dental Recruitment agency to find three specialists to join them.
“I knew our biggest weakness – because we are down in west Wales – was to attract specialists who were like-minded in the way that they work and that that was going to be hard.
“When I used Green Apple, they found me three specialists, one of whom we have taken on and the other one qualifies in a year’s time so we will probably go from having just myself to having three specialists.
“I don’t know if that was because of the pandemic and people were thinking differently about their life and where they wanted to live or Green Apple are just really good at finding people.”
Referrals’ ongoing role
Dental referrals are likely to continue to have a significant role to play in dental care, according to Dr Len D’Cruz, Principal Dentist at the Woodford Dental Care practice in Essex, which offers NHS and private treatment at its seven surgeries.
“Amongst all of our patients, we refer around 7-8% elsewhere for specialist treatment and oral medicine,” says D’Cruz. “That number has gone down in recent years because we are starting to do some things in-house – things like the orthodontics and the perio treatment.
“There are various benefits for the patient and the dental professional in referring them on. With kids, it is because of general anaesthesia or sedation because they are uncooperative or have a dental phobia that cannot be managed in the practice.
“With oral medicine, it’s because of complexity and they need a proper diagnosis especially when there are concerns over suspicious lesions but also non-dental facial pain. Our oral surgery referrals tend to be for complex impacted wisdom teeth, which our own oral surgery colleague can’t do and things like a patient who could be medically compromised.
“We have a very limited NHS orthodontic contract so the referrals on the NHS would be out of the practice, but all the private orthodontic treatment and a small number of NHS cases would be done here. Although the numbers have been going down, in general we will always need referrals out for reasons of patient choice and ensuring all the patients specific needs are catered for.”
Dr Ayodele Soyombo is a specialist in orthodontics practising in Dental Specialists – a primary care multidisciplinary dental practice that offers periodontic, orthodontic, endodontic, prosthodontic, oral surgery and implant treatments in three centres in Milton Keynes, St Albans and Melton Mowbray.
Soyombo says: “Dental referrals are very common and the majority of my clinical practice is by referral, but we have many self-referrals, which we are grateful for.
“The number of referrals has been increasing over the years, mainly because many appreciate the beautiful smile that orthodontics can give them and now that many adults have accepted the fixed appliance in its various forms (metal, ceramic, or lingual) as well as the aligners.
“Many adults now do not feel self-conscious with fixed braces and aligners have made orthodontics even more acceptable and they want the ‘Hollywood Smile’.”
Specialist treatment appear to be increasingly focused rather than within general dental practices, according to Dr Nicholas Daley, Principal Dentist at Daleys Dental Practice in Liverpool, which is actively looking for a new specialist in endodontics at the practice.
Daley says: “It’s just the way that the dental industry is now that for those specialism areas, it does need to be perhaps a specialist themselves providing a service rather than within a general practice. “I am a GDP and I always say they you can’t beat a good general practitioner, but it is useful to have the ability to be able to refer for difficult cases or cases where you feel you need to do that.”
Davies agrees, saying: “I’ve worked in general practice before I was a specialist and it’s not geared up for it. If you are doing just one thing, the whole practice is set up in one direction and you can offer a much better patient service.”
Daley says: “It’s probably 5% to 10% of patients that I see that I think need to be referred on to a specialist. Between 5-10% of people in the endodontic or the periodontic category could possibly need an endo or perio specialist’s help. However, it is difficult to find specialists out there and to get the right people.
“The main benefits to patients for sending referrals is to be able to offer better care to them. Also, I think looking at medicolegal things as well in this day and age, you have got to have something else in your back pocket to keep you safe. Having a possibility of a specialist referral – whether for perio or endo – there, it’s worthwhile.”
The covid-19 pandemic has taken its toll on dentistry with most practices having to close earlier this year while urgent care centres were set up to deal with extreme cases.
Dental practices, however, started to resume routine care in June in a phased approach, but the majority have begun running at less than a quarter of their pre-pandemic capacity.
NHS England has said there should be no legal impediment to dental practices providing routine dental care but the return of care should be staged with an initial focus on urgent and emergency care patients whose care was interrupted and those who need more frequent recalls.
Soyombo says: “During the shutdown, referrals dropped drastically and there is still a slow recovery. This has however given us the opportunity to catch up with the treatment of our existing patients who were not seen for several months.
“Interestingly we have seen an increase in self-referral patients. It is quite possible that the time at home gave many the opportunity to finally make important changes in their lives. With the safety requirements of Covid-19, we have revamped our practice and installed equipment to improve infection and aerosol control.”
D’Cruz says the pandemic has made work more complex, adding: “A number of practices haven’t got back up and running again and oral surgery referrals have been very difficult. With oral medicine, they are not accepting referrals and those are bouncing back. The hospitals appear not to be taking referrals so we’re struggling with that.” Davies concurs that the pandemic has taken its toll and paused many referrals, but the wheels are moving again.
“The dentists haven’t been able to refer because they haven’t been seeing the patients. From a NHS perspective, the waiting lists are staying pretty much the same because nobody’s being added to the list because they haven’t been seen.
“From a private perspective, people are contacting us directly and we have got a private waiting list now for examinations.”
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