# Problems with oral healthcare delivery systems Dr Mohammed Junaid, Senior Lecturer – Dental Public Health Image source Australian Broadcasting Corporation. https://www.abc.net.au/news/2023-08-23/dalby-uq-dental-clinic-improves-oral-health-indigenous-patients/102701604 . Government of Western Australia North Metropolitan Health Service Dental Health Services Dental Health Services, WA: https://www.dental.wa.gov.au/   Dr Mohammed Junaid Senior Lecturer – Dental Public Health *Image source: Australian Broadcasting Corporation. https://www.abc.net.au/news/2023-08-23/dalby-uq-dental-clinic-improves-oral-health-indigenous-patients/102701604 .* Government of Western Australia North Metropolitan Health Service Dental Health Services Dental Health Services, WA: https://www.dental.wa.gov.au/ Clinical photo: A dental team, including a dentist using loupes and two assistants in green scrubs, is treating a patient in a dental chair within a modern clinic setting. The image illustrates the concept of oral healthcare delivery systems, specifically showing a clinical environment likely associated with the Dalby UQ Dental Clinic or Western Australian Dental Health Services mentioned in the slide text. Logo: The coat of arms of Western Australia, featuring a shield with a black swan supported by two kangaroos, surmounted by a crown. # Acknowledgement of country I would like to acknowledge the traditional custodians of the land, the Whadjuk Noongar people, in whose land, I have recorded this lecture and pay my respects to elder’s past, present and emerging. Including to all those with Indigenous heritage who are listening to this recording. Image source: Linelelu Arts https://www.linleluarts.com.au/products/noongar-seasons  I would like to acknowledge the traditional custodians of the land, the Whadjuk Noongar people, in whose land, I have recorded this lecture and pay my respects to elder’s past, present and emerging. Including to all those with Indigenous heritage who are listening to this recording. *Image source: Linelelu Arts https://www.linleluarts.com.au/products/noongar-seasons* A cropped section of an Indigenous Australian dot painting featuring stylized representations of a white sea turtle, a black swan, and a kangaroo-like figure set against colorful backgrounds with traditional patterns. Learning outcomes * Describe the common problems with health care delivery. * Define the term ‘access to care’/‘barriers to care’. * Describe these problems from an Australian context. IMAGE SOURCE: https://www.dreamstime.com/illustration/learning-outcomes.html Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', Essential Dental Public Health (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024.  - Describe the common problems with health care delivery. - Define the term 'access to care'/'barriers to care'. - Describe these problems from an Australian context. *Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', Essential Dental Public Health (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024.* - ==Identify enablers as a concept commonly used when discussing health systems.== - ==Understand what a person experiences before meeting a doctor or dentist.== - ==Consider healthcare delivery problems from both a general and an Australian perspective.== > [!note] Lecturer — Earlier Lectures > The lecture followed two earlier lectures that established the health-system and oral-disease context. > > - The first lecture covered the components of healthcare systems and how healthcare delivery systems are structured globally and in Australia. > - The second lecture covered the burden of oral disease and the burden of disease among priority population groups identified by the Australian Institute of Health and Welfare. > - Earlier messages were that oral disease is disproportionately distributed, healthcare systems must respond to changing population needs, and multiple factors influence how a health system operates. Stock photo of a film clapperboard with the words 'LEARNING OUTCOMES' written in white chalk, surrounded by colorful pieces of chalk on a green background. This figure serves as a decorative header illustrating the slide's topic. # What should a good health care system look like? (adapted from Maxwell 1984) **Equitable** (fair) **Accessible** **Relevant to health needs** **Effective** (high quality) **Efficient & Sustainable** **Socially acceptable** Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', *Essential Dental Public Health* (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024. *(adapted from Maxwell 1984)* - **Equitable** (fair) - **Accessible** - **Relevant to health needs** - **Effective** (high quality) - **Efficient & Sustainable** - **Socially acceptable** *Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', Essential Dental Public Health (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024.* - ==Equity should provide functional services that improve people’s functional health across different social strata and ethnicities.== - ==Accessibility means that people can reach the health professional they need, and that the practice or service is designed to meet users’ needs.== - ==Affordability requires high-quality services to be available at a cost that is not excessively expensive.== - ==Sustainability requires financial consideration; providing services without considering the consequences for the health system can make it unsustainable.== - ==Acceptability means that services should be acceptable to all populations being served.== - ==Putting these principles into practice is highly complex, although they appear achievable.== > [!note] Lecturer — Macro-Level Context > Many healthcare systems remain largely biomedical, prioritising disease progression and treatment over prevention and wellbeing. > > - Hospitals, tertiary institutions and disease-treatment services consequently receive more attention than health promotion and prevention. > - Healthcare goals may focus on reducing disease burden without also promoting health, creating a mismatch between stated goals and resource distribution. > - Specialised services and institutions receive most resources, while health-promotive and preventive services receive fewer. > - Policymakers and non-dental professionals also influence healthcare delivery; their commitment to oral healthcare can either worsen or alleviate these problems. > [!note] Lecturer — Micro-Level Context > Micro-level problems occur at the practice level and involve interactions between practitioners and patients. They include how a practice is structured and organised, how practitioners respond to patient needs, and how practice behaviour can affect a patient’s ability to access care. ## Common problems in health care delivery ### Macro level * Treatment focus * Unclear goals * Maldistribution of resources * Structure and configuration of health care services * Lack of accountability ### Micro level * Communication problems * Adherence with dental advice * Access to dental care Modified from Plamping 1988. *** Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', *Essential Dental Public Health* (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024. - Treatment focus - Unclear goals - Maldistribution of resources - Structure and configuration of health care services - Lack of accountability - Communication problems - Adherence with dental advice - Access to dental care *(Modified from Plamping 1988)* *Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', Essential Dental Public Health (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024.* **Relationship between different types of health needs** Aubrey Sheiham, Georgois Tsakos. Oral Health Needs Assessment, Chapter 4, Community Oral Health, Quintessence books, pages:60-1 *Aubrey Sheiham, Georgois Tsakos. Oral Health Needs Assessment, Chapter 4, Community Oral Health, Quintessence books, pages:60-1* # Relationship between different types of health needs **Normative needs** Aubrey Sheiham, Georbios Tsakos. Oral Health Needs Assessment, Chapter 4, Community Oral Health, Quintessence books, pages:60-1  *Aubrey Sheiham, Georbios Tsakos. Oral Health Needs Assessment, Chapter 4, Community Oral Health, Quintessence books, pages:60-1* > [!note] Lecturer — Health Needs > Health needs refer to a person’s need for a health service. > > - Normative needs are detected by a professional, even when a person has dental caries or periodontal disease without being aware of it. > - These conditions may progress without the person identifying them, and the person may not recognise the need until seeing a practitioner. A solid blue rectangular box containing the text label "Normative needs" at the bottom, serving as a section header or title card for the concept. Relationship between different types of health needs **Normative needs** **Perceived needs** Aubrey Sheiham, Georgois Tsakos. Oral Health Needs Assessment, Chapter 4, Community Oral Health, Quintessence books, pages:60-1  - Normative needs - Perceived needs *Aubrey Sheiham, Georgois Tsakos. Oral Health Needs Assessment, Chapter 4, Community Oral Health, Quintessence books, pages:60-1* > [!note] Lecturer — Perceived Needs > Perceived needs occur when a person becomes subjectively aware that they have a health problem. > > - Examples include recognising that they have periodontal disease, tooth decay, or bleeding gums. > - Perceived needs represent only the visible part of a larger group of health needs because many normative needs remain hidden. > - Not everyone with a perceived need will demand care; an expressed need occurs when a person communicates or seeks help for the perceived problem. > - Some people know they have dental problems but do not approach a dental professional for assistance. > - A person may perceive a problem without experiencing enough impact to seek care. As symptoms become more severe, the condition may develop into an impact-related need, such as spontaneous bleeding, gum pain, or worsening gum problems. > - Not every impact-related need leads to a demand for care. A propensity-related need occurs when a person has developed the health-seeking behaviour or motivation to seek care. > - Patients seen in clinical practice generally have felt the impact of their condition, become aware of its possible negative consequences, and developed the motivation to seek care. > - Needs are unmet when the health system does not provide a service equivalent to the need, whether the need is normative, perceived, expressed, impact-related, or propensity-related. > [!example] Single Parent Considering Dental Care > A single parent may think about visiting a dentist but may prioritise the needs of their child or children. > > - Even if the parent has a dental problem, other daily responsibilities may prevent them from developing the propensity to seek care. > - This illustrates how the perception of need and readiness to seek care can be influenced by social circumstances. Labelled diagram: Two overlapping rectangles, a blue one labeled 'Normative needs' and a pink one labeled 'Perceived needs', illustrate the relationship between these two types of health needs. Interaction between "client" and health service <table> <tr> <th colspan="2">First phase</th> <tr> <td>Lay referrals and interventions</td> <td>Health care organization</td> </tr> <tr> <td>Geographic availability</td> <td>Ability to pay</td> </tr> <tr> <td>Self-care, self-help</td> <td>Geographical availability</td> </tr> </table> <table> <tr> <td>Perception of need</td> <td>Identify a source of care</td> <td>Gain entry to health care</td> <td>Obtain health care</td> <td>Achieve a desirable outcome</td> </tr> </table> <table> <tr> <td colspan="2">Second phase</td> </tr> </table> Cultural variation Presentation and knowledge of disease Triggers Perceptions of costs and benefits Fit between health care and patient: Availability Affordability Acceptability Accessibility Accommodation Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', *Essential Dental Public Health* (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024.  #### First Phase - Lay referrals and interventions - Health care organization - Geographic availability - Ability to pay - Self-care, self-help #### Pathway of Care 1. Perception of need 2. Identify a source of care 3. Gain entry to health care 4. Obtain health care 5. Achieve a desirable outcome #### Second Phase - Cultural variation - Presentation and knowledge of disease - Triggers - Perceptions of costs and benefits #### Fit Between Health Care and Patient - Availability - Affordability - Acceptability - Accessibility - Accommodation *Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', Essential Dental Public Health (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024.* > [!note] Lecturer — Care-Seeking Pathway > A patient’s need for care alone is not sufficient to complete the pathway. > > - The person must become ready to demand care and successfully move through the healthcare system. > - Influencing factors include social demographic, social psychological, social cultural, economic, geographical, predisposing, enabling, and need-related factors. > [!example] Bleeding Gums and Periodontal Therapy > A person may first notice that their gums are bleeding, but mild bleeding may not lead to a request for care. > > - If the bleeding becomes spontaneous or is accompanied by pain, the person may recognise a greater impact. > - After developing the motivation to seek care, they may attend a dental service. > - The desired outcome would be receiving suitable periodontal therapy. > [!note] Lecturer — Patient Experience > A considerable amount may have occurred in a patient’s life before they arrive at a practice. > > - Patients may cancel appointments or fail to attend because they find it difficult to prepare themselves mentally to obtain care. > - Practitioners should recognise this background and respond empathetically rather than assuming that the appointment is the first significant step in the care process. This figure is a flowchart illustrating the interaction between a client and health services, divided into two stages: 'First phase' (influenced by lay referrals and healthcare organization) and 'Second phase'. The central process flows through five sequential steps: Perception of need, Identify a source of care, Gain entry to health care, Obtain health care, and Achieve a desirable outcome. External factors influencing these phases include cultural variation, disease knowledge, and triggers at the start, and the fit between health care and patient (availability, affordability, acceptability, accessibility, accommodation) towards the end. Models of access to health care | Andersen and Newman 1972 | McKinlay 1972 | Penchansky and Thomas 1981 | | :--- | :--- | :--- | | **Predisposing factors**<br>(Propensity to use) | Socio-demographic | | | | Socio-psychological | | | | Socio-cultural | | | **Enabling factors**<br>(Aids and barriers to use) | Economic factors | | | | Geographic factors | Accessibility, availability, acceptability,<br>accommodation, affordability<br> =fit between services and client | | | Organization | | | **Factors related to need** | | | Gibson, B. et al. 2001. Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', *Essential Dental Public Health* (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024. | Andersen and Newman 1972 | McKinlay 1972 | Penchansky and Thomas 1981 | | :--- | :--- | :--- | | **Predisposing factors**<br>(Propensity to use) | Socio-demographic<br>Socio-psychological<br>Socio-cultural | | | **Enabling factors**<br>(Aids and barriers to use) | Economic factors<br>Geographic factors<br>Organization | Accessibility, availability, acceptability, accommodation, affordability<br>= fit between services and client | | **Factors related to need** | | | *Gibson, B. et al. 2001.* *Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', Essential Dental Public Health (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024.* - Availability of services - Accessibility of services - Affordability of services - Acceptability of services - Accommodation of services penchansky and Thomas 1981. Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', *Essential Dental Public Health* (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024. - Availability of services - Accessibility of services - Affordability of services - Acceptability of services - Accommodation of services *Penchansky and Thomas 1981.* *Adapted from: Daly, Blánaid, and others, 'Problems with health care delivery', Essential Dental Public Health (Oxford, 2013; online edn, Oxford Academic, 12 Nov. 2020), https://doi.org/10.1093/oso/9780199679379.003.0030, accessed 3 Aug. 2024.* > [!note] Lecturer — Access Dimensions > Models simplify the complexity of how people access health services. The access factors are shaped by social, psychological, cultural, economic and geographical circumstances, and the five dimensions interact rather than operating as completely separate categories. > [!example] Remote Access to Orthodontic Services > A person living remotely may require orthodontic care, but even when the service exists elsewhere, they may need to travel thousands of kilometres to obtain it. This demonstrates how the distribution of services can limit availability. > [!note] Lecturer — Dental Care Costs > In Australia, most dental care has been kept outside Medicare. People may therefore need private insurance or personal funds to pay for care, and the cost can cause them to avoid or delay treatment, increasing the burden of disease. <table> <tr> <th colspan="3"><em>Understanding aspects of health service use</em></th> </tr> <tr> <th>Aspect of<br/>health service</th> <th>Context</th> <th>Challenge/s</th> </tr> <tr> <td>Availability</td> <td>How well distributed health services are?<br/>Example: dentist to population ratio.</td> <td>People living in deprived communities with greater health need have fewer doctors and dentists compared to richer areas with fewer health care needs – Inverse care law (Tudor Hart 1971).<br/>Lack of specialised dental services.</td> </tr> <tr> <td>Accessibility</td> <td>Two dimensions (i) Location – how far do I need to travel to avail service? (ii) Spatial dimension – Can I physically access the premises?</td> <td>People living in remote and rural areas often must travel far to access basic health care service.<br/>Individuals with disability do not have access to many disability friendly practices.</td> </tr> <tr> <td>Affordability</td> <td>Direct and indirect costs of dental care. Financial model of health system.</td> <td>Direct costs of dental care – poorly funded health system $\rightarrow$ predominantly out of pocket care would lead to increased disease burden.<br/>Indirect costs like time of work, travel costs, cost of childcare whist at dentist.</td> </tr> <tr> <td>Acceptability</td> <td>Expectations on how a health service should look like.</td> <td>Lack of a culturally trained workforce.</td> </tr> <tr> <td>Accommodation</td> <td>Flexibility of health care service to suit patient needs.</td> <td>Long waitlist for dental care especially specialist dental services.</td> </tr> </table> | Aspect of Health Service | Context | Challenge/s | | :--- | :--- | :--- | | **Availability** | How well distributed health services are?<br>Example: dentist to population ratio. | People living in deprived communities with greater health need have fewer doctors and dentists compared to richer areas with fewer health care needs – Inverse care law (Tudor Hart 1971).<br>Lack of specialised dental services. | | **Accessibility** | Two dimensions:<br>1. Location – how far do I need to travel to avail service?<br>2. Spatial dimension – Can I physically access the premises? | People living in remote and rural areas often must travel far to access basic health care service.<br>Individuals with disability do not have access to many disability friendly practices. | | **Affordability** | Direct and indirect costs of dental care. Financial model of health system. | Direct costs of dental care – poorly funded health system → predominantly out of pocket care would lead to increased disease burden.<br>Indirect costs like time of work, travel costs, cost of childcare whist at dentist. | | **Acceptability** | Expectations on how a health service should look like. | Lack of a culturally trained workforce. | | **Accommodation** | Flexibility of health care service to suit patient needs. | Long waitlist for dental care especially specialist dental services. | > [!note] Lecturer — Cultural Acceptability > Globalisation has contributed to a less homogeneous society, so cultural differences influence what patients expect from health services. Professionals may prefer patients who pay well, cooperate with treatment and are less demanding, but the responsibility lies with professionals to understand patient needs and provide care with empathy and appropriateness. > [!example] Oral Health Centre of Western Australia > Eligible patients seeking specialised services at the Oral Health Centre of Western Australia may have difficulty accessing care without entering a waiting list. Efforts are being made to reduce these waiting lists, but they remain an issue in public dental services; the example also illustrates how accommodation is connected to availability, accessibility, affordability and acceptability. > [!note] Lecturer — Patient Interaction > Patient-related barriers largely arise during the first phase of interaction with the health service. > > - The person recognises a need, develops a perception that care is required, experiences the condition’s impact, and develops a propensity to seek care. > - The person then identifies a source of care and decides whether they can reach and use the service. > - Relevant influences include social demographic, social psychological, social cultural, economic, and geographical circumstances. > - Family responsibilities, competing problems in daily life, and whether the person has developed health-seeking behaviour also influence access. > [!note] Lecturer — Dentist Interaction > Dentist-related barriers concern how professionals influence the patient’s interaction with the service. > > - Relevant factors include how the practice is structured and how practitioners communicate with patients. > - Professionals should respond to patient needs empathetically and deliver culturally appropriate care. > - Practitioners need to recognise that patients may have different expectations, while practices should be flexible and accommodating. > [!note] Lecturer — System Factors > System-related barriers reflect wider, macro-level problems in the organisation and financing of care. > > - Healthcare systems may have a biomedical focus, emphasise treatment rather than prevention and health promotion, or have unclear goals. > - Resources may be distributed towards hospitals and specialised services, leaving limited resources for preventive and health-promotive services. > - Policymakers and non-dental professionals influence these arrangements, which can contribute to unequal distribution of doctors, dentists, and specialised services. > - Other barriers include the financial structure of dental care, long waiting lists in public dental services, and limited disability-friendly or culturally appropriate services. <!-- TABLE --> # **Barriers to dental health service use** | **Patient related factors** | **Dentist related factors** | | :--- | :--- | | * Perceived need | * Professional attitude | | * Fatalistic attitude | * Perceived competence of dentist by patients | | * Lack of awareness | * Availability of dentists with specialist skills | | * Anxiety/fear | | | * Past dental experiences | | | * Disability - mental and/or physical | | | * Time availability - getting time off work | | | **System related factors** | | | | | | * Cost | | | * Availability of NHS services | | | * Physical barriers - e.g. surgery accessible only via steps/stairs | | | * Rural and remote area issues | | | * Availability of transport | | Chestnutt, Ivor G.. **Dental Public Health at a Glance**, John Wiley & Sons, Incorporated, 2016. *ProQuest Ebook Central*, https://ebookcentral.proquest.com/lib/uwa/detail.action?docID=7103897. #### Patient Related Factors - Perceived need - Fatalistic attitude - Lack of awareness - Anxiety/fear - Past dental experiences - Disability – mental and/or physical - Time availability – getting time off work #### Dentist Related Factors - Professional attitude - Perceived competence of dentist by patients - Availability of dentists with specialist skills #### System Related Factors - Cost - Availability of NHS services - Physical barriers – e.g., surgery accessible only via steps/stairs - Rural and remote area issues - Availability of transport *Chestnutt, Ivor G., Dental Public Health at a Glance, John Wiley & Sons, Incorporated, 2016. ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/uwa/detail.action?docID=7103897.* # Quick revision... 1. Characteristics of an ideal health system. 2. Macro and microlevel problems in health care systems. 3. Interaction between a patient/ client and health service. 4. Factors influencing Phase II of health service use: a. Availability b. Accessibility c. Affordability d. Acceptability e. Accommodation 5. Barriers to oral health service use KEEP CALM AND DO SOME REVISION Revise! Image sources: https://giphy.com/explore/revision  1. Characteristics of an ideal health system 2. Macro and microlevel problems in health care systems 3. Interaction between a patient/client and health service 4. Factors influencing Phase II of health service use: - Availability - Accessibility - Affordability - Acceptability - Accommodation 5. Barriers to oral health service use > KEEP CALM AND DO SOME REVISION Revise! Image sources: https://giphy.com/explore/revision > [!note] Lecturer — Lecture Coverage > The lecturer specified the characteristics of an ideal healthcare system as equity, accessibility, relevance, quality, affordability, sustainability, and acceptability. > > - Healthcare delivery problems occur at both the macro or organisational level and the micro or practice level. > - Health needs include normative, perceived, expressed, impact-related, propensity-related, and unmet needs. > - Patient–health service interaction has two phases: becoming ready to seek care, then obtaining care and achieving a desirable health outcome. > - Barriers can be grouped into patient-related, dentist-related, and system-related factors. > - The next recording will examine challenges in the Australian oral health system using a recent Senate inquiry as the guiding document. Cartoon clip art of a blond student sitting at a desk with an open book, looking stressed while talking on a red telephone; the image serves as a decorative illustration for the slide's revision theme. 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