Full text of DOI:10.1038/sj.bdj.4800415a

RESEARCH
oral surgery
Referral patterns and the referral system
for oral surgery care. Part 1: General
dental practitioner referral patterns
1
2
3
4
P. Coulthard, I. Kazakou, R. Koron, and H. V. Worthington,
Objective To investigate current GDP oral surgery referral
patterns given the anticipated change since the introduction by
the General Dental Council of the specialty of surgical dentistry.
DesignPostal questionnaire.
among general medical practitioners in their rates of referral to
hospital. This variation was interpreted by the Department of
Health (1987) as indicating inefficient use of resources. Data sys-
tems have since been established to monitor referrals from general
medical practitioners but such systems have not been established
for dental practitioner referrals and still relatively little is known
about these. Several studies have investigated dental practitioners’
Setting 400 GDPs in Greater Manchester.
Results 84% participation rate. 69% of dentists made a referral
because of anticipated difficulty of surgery and 49% because of
the complex nature of the patients’ medical history. Practitioners referral to orthodontic services2,3 but less is known about referral
who had undergone some oral surgery postgraduate training
were more likely to undertake more surgery in their practices
(P < 0.01) and to refer more patients for specialist care
(P < 0.05). While female practitioners rated their own surgical
confidence less highly than male practitioners (P < 0.001),
and younger practitioners less than their older colleagues
(P < 0.05), there was no significant difference in the number
of referrals made.
to oral surgery services. It is important to investigate these patterns
because the decision to refer to specialist hospital care has social
and economic implications, and because they provide information
about the practitioners’ preferences. The latter is particularly
important at this time in the specialty of oral and maxillofacial
surgery. It is anticipated that new forms of surgical practice will
develop following the introduction by the General Dental Council
of specialist lists for oral surgery and in particular for surgical den-
tistry.4 Hospital treatment is often less cost-effective than similar
treatment in a primary care setting5 and as there is an increasing
ConclusionThe most common reasons for referral were the
anticipated difficulty of surgery and patient medical
compromise. There was a wide variation between practitioners in volume of oral surgery being undertaken,6 referral patterns may
the number of patients referred for specialist care. Postgraduate
oral surgery training was identified as a factor contributing to
this variation. Other practitioner variables, such as sex,
experience and type of practice were not found to contribute.
well be expected to change.
Study objective
To investigate the referral patterns of general dental practitioners to
specialist oral surgery services in Greater Manchester.
he referral system is a key feature of the British health service. Methods
T
Primary care practitioners act as the gate-keepers of expensive A sample of 400 general dental practitioners was randomly selected
high-technology specialist care, using their professional skill in from the Central Manchester NHS Trust database of Greater Man-
referring patients to the most appropriate specialist at the most chester general dental practitioners. The study sample did not
appropriate time. While contributing to the relatively low cost of include any dental practitioners working completely indepen-
British health care, patients do have less autonomy than in many dently from the National Health Service, as our initial source did
other countries where patients have direct access to specialists.1 If not include these practitioners. The study design was two stage
this is the case then it is important that the referral system in Britain cross-sectional. Following piloting to check absence of ambiguity, a
is working effectively. Treatment as and when it is needed should be questionnaire was sent by post to each practitioner in the study.
available to meet the patients’ needs.
This study collected data in the form of dentists’ opinions of their
Prior to the reorganization of the UK National Health Service referral practice.
(NHS) in 1991 there was little information available about referral
patterns of general practitioners to hospital services. However,
some research studies had suggested that there was wide variation Section 1
The questionnaire consisted of three sections:
This section collected general information, including practice
experience and type of practice. Information about postgraduate
oral surgery training and level of confidence in performing oral
surgery procedures was also requested.
1
2
3*
Lecturer in Oral Surgery, Postgraduate Student in Oral Surgery, Senior House
4
Officer, Reader in Dental Statistics, Manchester University Dental Hospital,
Higher Cambridge Street, Manchester M15 6FH
*Present address: Charles Clifford Dental Hospital, Wellesley Road,
Sheffield S10 2SZ
Section 2
Correspondence to: Dr Paul Coulthard, Oral and Maxillofacial Surgery,
Manchester University Dental Hospital, Higher Cambridge Street,
Manchester M15 6FH
In this section, GDPs were asked to indicate their number of oral
surgery referrals, reasons for referral and place of referral.
REFEREED PAPER
Section 3
Received 14.05.99; accepted 02.11.99
© British Dental Journal 2000; 188: 142–145
GDPs were asked their opinion of the current referral system
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RESEARCH
oral surgery
Table 1 Volume of oral surgery undertaken in general practice and number of oral surgery referrals to
a specialist per month
Number of practice procedures
Number of GDP’s
Percentage of GDPs
0–10
271
81
11–20
39
21–30
14
31–40
41–50
1
> 50
4
7
2
12
4
< 1
1
Number of referrals
Number of GDP’s
Percentage of GDPs
0–5
252
75
6–10
72
21
11–15
11
16–20
1
3
< 1
including expectations of early patient consultation and desire to
be more directly involved with the patient’s consultation. This sec-
tion is reported in Part 2 of this study.
Table 2 Reasons for GDP referral to specialist oral
surgery services
Reason
Number of GDPs
giving reason (%)
Results
Anticipated difficulty of surgery
233 (69)
165 (49)
106 (32)
98 (29)
95 (28)
38 (11)
Response rate
Complicated medical history
From 400 questionnaires mailed to GDPs in Greater Manchester,
336 replies were received. This gave a participation rate of 84% and
a sample representing just under half of the dental practitioners in
Greater Manchester.
Need of second opinion
Preference not to undertake surgical procedures
Lack of appropriate facilities or staff
Emergency management of pain/swelling/haemorrhage
Personal details
Half (48%) of the practitioners were in the 20–40 years’ age range score than those less experienced (chi-squared linear trend = 14.9;
and half (52%) were in the 41–70 years’ age range. Almost half 1 degree of freedom; P = 0.03) as were those who had undergone
(49%) were Manchester graduates, with the remainder distributed some form of postgraduate oral surgery training (chi-squared lin-
from the remainder of schools in the UK and the Irish Republic. ear trend = 20.3; 1 degree of freedom; P < 0.001). Postgraduate
Two hundred and thirty eight (71%) of respondents were male and oral surgery training which included practical hands-on operative
98 (29%) were female but any sex bias was reduced by the large work was a more powerful predictor of confidence than more lim-
sample size. A greater proportion of the younger age range group ited postgraduate experience (chi-squared linear trend = 8.0; 1
was female.
degree of freedom P = 0.005).
Postgraduate oral surgery training
Number of oral surgery patients referred
Eighty (24%) of the general dental practitioners had taken a short The majority of practitioners (75%) reported referring between 0
postgraduate course such as a Section 63 course and eight (2%) had and 5 patients per month. One (0.3%) practitioner gave a referral
obtained a higher degree (MSc) in oral surgery. Thirty four (10%) score of between 16 and 20 patients per month. The number of
had worked as a house officer or senior house officer in oral surgery patients referred by GDPs is shown in Table 1. Practitioners who had
and 19 (6%) as a clinical assistant. Thirty four (10%) had received undergone some postgraduate oral surgery training were more likely
some training as part of vocational training. One hundred and to refer more patients than those who had not (chi-squared = 7.5; 1
ninety three (57%) practitioners had not received any postgraduate degree of freedom; P = 0.006). Postgraduate oral surgery training
oral surgery training.
which included practical hands-on operative work was not a more
powerful predictor of the number of patients referred than more lim-
ited postgraduate experience (chi-squared linear trend = 0.53; 1
Type of practice and oral surgery undertaken in general practice
Most (80%) practitioners worked in multi-handed practices, with degree of freedom P = 0.47). There was no significant difference in
only 67 (20%) working alone. The vast majority of practitioners the number of patients referred by practitioners according to sex or
(81%) reported carrying out few (between 0 and 10) oral surgery pro- to the number of years spent in practice or the type of practice.
cedures per month. However, 4 (1%) practitioners carried out more
than 50 procedures per month. The volume of oral surgery under- Reasons for making an oral surgery referral
taken by GDPs is shown in Table 1. Practitioners who had undergone Six potential reasons for referral of a patient to a specialist oral
some postgraduate oral surgery training were more likely to carry out surgery service were listed in the questionnaire. Respondents
oral surgery in practice than those who had not (chi-squared = 10.0; 1 were invited to state which of these were their reasons for refer-
degree of freedom; P = 0.002). There was no significant difference in ral. The results are shown in Table 2. The commonest two rea-
the number of surgical procedures carried out by practitioners sons for referral were the anticipated difficulty of surgery and
according to sex or to the number of years spent in practice.
the complicated nature of the medical history. Respondents
were not specifically asked to specify further reasons, although
the opportunity for additional comment was present. Some
GDP confidence in performing oral surgery procedures
General practitioners were asked to rate their level of confidence in respondents (12%) complained that their main reason for refer-
performing oral surgery in practice from 1 (not confident) to 4 ring patients for oral surgery treatment was that the NHS fee
(very confident). Thirty nine (12%) gave a confidence score of 1 scale did not adequately reimburse for this type of treatment in
and 29 (9%) a score of 4 with the remainder giving scores of 2 or 3. the General Dental Service.
Male practitioners were found to rate their confidence more highly
than female practitioners (chi-squared linear trend = 14.0; 1 Place of referral
degree of freedom; P < 0.001). Practitioners who had spent more Ninety three per cent of practitioners said that they would refer
years in general practice were more likely to give higher confidence more than 75% of their patients to the hospital oral and maxillofa-
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RESEARCH
oral surgery
cial surgery service with few practitioners referring to a community longer in practice reported more surgical confidence, they referred
or practice specialist service.
no fewer patients than those less experienced who had less confi-
dence. A similar finding has been observed in medical practice
where, contrary to popular belief, more experienced doctors made
Factors influencing choice of oral surgery specialist service
The most important factors in choosing an oral surgery service no less use of hospital services than their younger colleagues.10 Single
were reported to be the length of the waiting list for consultation handed practitioners referred no more patients than those working
and treatment and personal knowledge of the surgeon, both influ- in multihanded practices. This has also been shown to be the case in
encing 57% of dentists (Table 3). Ease of access for the patient and several studies for medical practitioners.7,10,11
the perceived standard of treatment offered by the specialist was an
A wide variation between practitioners in the number of patients
influencing factor for 52%. One third (31%) of dentists were influ- referred per month was observed. While no attempt was made to
enced by the ease of making the consultation appointment in calculate referral rates by relating the number of referrals to the
choosing their service provider and 27% would choose according total number of patients under the care of each dentist, similar vari-
to the type of surgical treatment required. The standard of the spe- ation has been described in orthodontic referrals as well as in stud-
cialist’s report returned to the practitioner was also an influencing ies investigating referral from general medical practice to
factor for 14%.
secondary care providers.2,10 Variation in referral rates may imply
that one practitioner is referring inappropriately or conversely that
another is denying the benefit of specialist care to his or her
patients. However, care must be taken in drawing such conclusions
even when taking into account the number of patients on a dentist’s
list. It could be that a practitioner has a large number of patients
registered but is gradually reducing his workload and his list size
bears little relation to the number of patients he or she sees. Alter-
natively, one practitioner may see many more casual patients than
another and this may skew the referral rate. Similarly, practices dif-
fer in age structure. A particular practice may provide care for a
large number of college students and this may increase the number
of referrals for third molar surgery.
Table 3 Factors influencing choice of oral surgery treatment
provider (total number of dentists = 336)
Factor
Number (%)
Length of waiting list
190 (57)
190 (56)
174 (52)
173 (52)
105 (31)
89 (27)
Personal knowledge of surgeon
Ease of access for the patient
Standard of treatment
Ease of making consultation appointment
Type of surgery required
Standard of surgeon’s report
48 (14)
Some variation in referral rates can be expected because of
random variation in the presentation of patients requiring referral,
that is, because of chance. Moore and Roland have described a
mathematical model to calculate the amount of variation in rates of
referral that is likely to be caused by chance alone.12 However, this
Discussion
The study area and sample
The study area was well suited to a study of this nature as it has a model assumes referral from medical practices of average list size of
number of oral and maxillofacial surgery hospital departments and 2,000 patients per doctor and to medical specialties in larger num-
also community clinics and general dental practices offering an bers than occur to dental specialties. This model may not therefore
oral surgery service. However the study did not take into account be transferable to dental referrals.
private referrals or referrals from general practitioners working
independently from the NHS.
Reasons for referral
The most common reasons for the dentists in this study to refer a
patient to a specialist oral surgery service were the anticipated diffi-
General dental practice oral surgery and referrals
Male practitioners reported significantly more confidence in culty of performing the surgery and the complicated nature of the
performing their own oral surgery than female practitioners. medical history. The same reasons have been reported by Absi who
However, female practitioners carried out no less surgery in prac- suggested that 70% of their medically compromised study patients
tice and referred no more patients to a specialist service than male had no special requirements other than those available in the general
practitioners confirming that while they expressed less confidence, dental service (GDS).13 An alternative view has been put by Sadler
they were not less capable. Practitioners who had undergone some who advised that despite the advantage of cost-effectiveness of oral
postgraduate oral surgery training also reported more surgical con- surgery treatment in primary rather than secondary care, some
fidence, particularly those having hands-on operating experience. patients with medical compromise would be better managed by the
These practitioners carried out more surgery in practice themselves hospital service.14 Absi13 reasoned that a large proportion of patients
but also referred more patients to specialist facilities. While there were unnecessarily receiving treatment in hospital because most
are no simple indicators that referral pattern may reflect differences were in fact treated by very junior staff. However, patients were under
in knowledge, other authors have suggested that background, the care of consultants and the treatment plan for management is
training, and specialist interests might account for at least some of likely to have involved senior staff. Perhaps more medically compro-
the variation. Forsyth and Logan showed that medical practitioners mised patients could only be managed in the primary care setting if
who held clinical assistantships in hospitals had rates of referral specialist advice were more readily accessible. Telemedicine, as
which were much the same as their colleagues, and that degrees and described in Part 2 of this study, may offer a feasible method for the
diplomas held bore relationship to referral behaviour.7 However a practitioner to improve communication with the specialist.
later study by Reynolds et al. showed that doctors with particular
experience in otorhinolarynology and opthalmology had higher undertaking oral surgery or the lack of facilities or appropriately
rates of referral to these specialties.8
trained staff. Some respondents offered that a reason for referral
Other reasons included the need for a second opinion, dislike of
While Matthews has reported that new graduates may carry out was their perceived inadequacy of the NHS fee to undertake oral
more oral surgery as a possible reflection of improved surgical teach- surgery in practice. Another problem raised in other studies is the
ing and confidence in performing minor oral surgery,9 more experi- anomaly that patients have to pay toward the cost of treatment in
enced practitioners were found to carry out their own oral surgery the GDS when hospital treatment is free.14,15
with significantly more confidence than those who had spent less
Only a small number (11%) of dentists referred patients for
time in general practice. However, while practitioners who had spent emergency relief of pain, swelling or haemorrhage. This suggests
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oral surgery
that despite an almost twofold increase in the provision of emer- for specialist care. Postgraduate oral surgery training was identified
gency dental care in the GDS since 1989,15 most dentists were oper- as a factor contributing to this variation. Other factors, such as sex,
ating their own emergency service successfully.
The understanding of oral surgery referral rates is confounded
experience and type of practice were not found to contribute.
This study has focused on the issue of general dental practitioner
because some general dental practitioners are in fact able to provide referral patterns to specialist oral surgery services. It must be
dentoalveolar surgery treatment themselves in their practices. remembered that this is only one facet of the interface between pri-
Indeed in this study four (1%) practitioners carried out more than mary and secondary care and care must be taken in interpreting the
50 oral surgery procedures per month. Personal preference, as results. They do not tell us about the quality of care and health out-
already mentioned, is another factor. All dentists are expected to be comes, although this study indicates that practitioners wish to have
competent on graduation to undertake oral surgery procedures information about these. Higher referrers are not necessarily wast-
commonly undertaken in general dental practice16 but a practi- ing specialist resources and low referrers denying care to their
tioner may exercise his clinical freedom to pursue a specialist inter- patients. Therefore while politicians and health service managers
est or limit his oral surgery practice.
may assume reducing variation in referrals will reduce costs, this
may not necessarily be the case as it may involve increasing referrals
from low referrers as well as reducing referral by high referrers.
Choice of specialist provider
In the past, British General Medical Practitioners (GMPs) have
been free to refer their patients to any hospital or consultant clinic
in the country and the same strategy was followed by General Den-
tal Practitioners (GDPs). However, with the introduction of the
internal market in healthcare, following the 1990 NHS and Com-
munity Care Act, there have been some limitations to this freedom.
Irrespective of these, there are practical limitations to referral.1 The
most obvious practical limitation is the distance that a patient may
have to travel to seek specialist care, and certainly most GMP refer-
rals go the hospital nearest to the practice. In this study most refer-
rals were to the hospital service rather than a specialist service in the
primary care setting of the practice or community clinic. As the
hospital service has traditionally been the only service available,
this is not unexpected, but with the advent of surgical dentistry,
change may be anticipated. Other factors are also known to influ-
ence referral patterns. These include transport available to the
patient, the length of the waiting list for consultation and treat-
ment, the preference of the referrer for a particular consultant to
care for his patient, technical facilities available and the perceived
standard of treatment. In this study the most important factors in
choosing an oral surgery specialist provider were the length of the
waiting list for consultation and treatment, and personal knowledge
of the surgeon. Dentists must be provided with accurate and up-to-
date information about waiting times if they are to make informed
decisions. Preferred specialist has been shown to be an important
factor for practitioners in other studies. In one study, 93% of medical
practitioner referrals went to a named consultant.17
The authors thank all the Greater Manchester dental practitioners who took the
time to complete the questionnaire.
1
Coulter A. The interface between primary and secondary care. In Roland M
and Coulter A. (eds) Hospital referrals. pp 1-14 Oxford: Oxford General
Practice Series, 1992.
2
3
O’Brien K, McComb J L, Fox N, Bearn D and Wright J. Do dentists refer
orthodontic patients inappropiately? Br Dent J 1996; 181: 132-136.
Bowden D, Pender N, Hussain J, Morris T and Russell J. An attempt to
influence the referral of orthodontic patients to hospital orthodontic
departments. Health Trends 1996; 28: 67-70.
4
5
6
General Dental Council. Specialist Dental Lists. London, April 1998.
Flasher H A. Wisdom tooth waiting lists. Br Dent J 1990; 168: 50.
Thomas D, Walker R, Smith A and Shepherd J. The provision of oral
surgery services in England and Wales 1984-1991. Br Dent J 1994; 176:
215-219.
7
8
Forsyth G, Logan R F L. Gateway or dividing line? A study of hospital
outpatients in the 1960s. Oxford: Oxford University Press,1968.
Reynolds G A, Chitnis J G and Roland M O. General practitioner
outpatient referrals: do good doctors refer more patients to hospital?
B Med J 1991; 302: 1250-1251.
9
Matthews R W, Porter S R, Scully C, Levers B G H. Confidence levels of new
UK dental graduates. J Dent Res 1991; 70: 726.
10 Wikin D and Smith A G. Variation in general practitioners’ referral rates to
consultants. J R College Gen Prac 1987; 37: 350-353.
11 Scott R, Gilmore M. Studies of hospital outpatients services: 1 In G
McLachlan (ed) The Edinburgh Hospitals. Problems and Progress in Medical
Care. pp3-41 Oxford: Oxford University Press, 1966.
12 Moore A T and Roland M O. How much variation in referral rates among
general practitioners is due to chance? Br Med J 1989; 302: 1250-1252.
13 Absi E G, Satterthwaite J, Shepherd J P, Thomas D W. The appropriateness
of referral of medically compromised dental patients to hospital. Br J Oral
Maxillofac Surg 1997; 35: 133-136.
14 Sadler A, Davidson M, Houpis C, Watt-Smith S. Specialist practice for
minor oral surgery: a comparative audit of third molar surgery. Br Dent J
1993; 174: 273-277.
15 Crawford A N. Recalled dental attendance; its cost to the NHS. Br Dent J
1994; 176: 363-364.
16 General Dental Council. The first five years. The undergraduate dental
curriculum. 1997.
17 Bradlow J, Coulter A, Brookes P. Patterns of referral. Health Services
Research Unit, Oxford, 1992.
The standard of care provided by the specialist unit was also
important to the dentists in this study. However the perceived stan-
dard of care and actual standard of care may of course be different.
This emphasises the importance of progression toward the routine
measurement of health outcomes and dissemination of these to the
primary care practitioners.
Conclusions
The most common reasons for referral were the anticipated diffi-
culty of surgery and patient medical compromise. There was a wide
variation between practitioners in the number of patient referred
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