Article
The opening of the School of Dentistry at UCLan in 2007 was an initiative designed to deliver a BDS degree predominantly in a primary care setting through a number of regional Dental Education Centres. Originally established in conjunction with the University of Liverpool, the Dental School at UCLan became fully independent in 2011. The school has been successful and, following an inspection by the General Dental Council in 2014, was commended for many aspects of its provision. The Department of Health in England had commissioned two new UK dental schools in 2004–05, with these to focus on education for graduate entry students within the primary care sector.1
The School was established by the Cumbria and Lancashire Medical and Dental Education Consortium, comprising the Universities of Central Lancashire, Cumbria, Liverpool and Lancaster, in association with the Primary Care Trusts of Blackpool, Cumbria, East Lancashire and North Lancashire in response to a perceived shortage of NHS primary dental care in the North-West.
For the first four years UCLan delivered the curriculum of the University of Liverpool, which had pioneered the four-year graduate entry course for dentistry. However, delivering a traditional curriculum within a non-traditional environment was not without its difficulties for both institutions. In 2011, The School developed its own curriculum specifically designed for its unique ‘hub and spoke’ mode of delivery based within primary care.
This model received favourable comment from the General Dental Council (GDC) during its recent inspection of the course in 2014:
‘The inspection panel was impressed by this modern, modular programme which is delivered in the main across a number of Dental Education Centres (DECs) and Extended Training Practices (ETPs). The course has been designed to emphasise the practice of primary care dentistry without jeopardizing the students' exposure to secondary care. In the Dental Education Centres all clinical work is carried out in multipurpose clinics to ensure that students achieve a good experience of integrated care.’
Structure of the BDS degree course
The course comprises a graduate entry pathway, directly onto year two of a five-year programme and requires applicants to have a relevant 2:1 degree within biomedical sciences. When the students accept their place on the course they also accept their place allocation at one of the four similarly-designed Dental Education Centres (DECs), which then becomes their base for the last three years of their clinical training.
The first year of the course is based at the Allen Building on the UCLan campus in Preston (Figure 1). This purpose-built facility cost £5.25 million and has one of the most sophisticated phantom head rooms in Europe, as well as five fully functional surgeries.
The Dental Education Centres (DECs)
The DECs are all based in established primary care settings situated in areas of high dental need across the North West of England: Accrington, Blackpool, Carlisle and Morecambe (Figure 2). The students make regular visits to their DEC throughout the first year and after their ‘Clinical Readiness’ exam they begin to treat patients.
Each of the DECs has a number of cubicle units and separate surgeries for more advanced treatment. There is a separate radiography room with digital OPT and intra-oral X-ray machines in the surgeries. The students are expected to keep records using Software of Excellence from day one of their clinical training.
In contrast to traditional dental schools, from their first patient the students are responsible for delivering all the care within the treatment plan in the one clinic, rather than moving the patient between different hospital departments as happens in traditional Dental Hospitals. The high staff to student ratio in the DECs also allows a member of staff to step in and complete the treatment if the student encounters a clinical problem beyond his/her level of competence.
The teaching and supervising staff all have extensive primary care experience and the DEC environment is ideal for training students to work in primary care which is, of course, where the majority will work once qualified.
The patients are asked, before they attend, if they wish to be considered for treatment by dental students. They are told that they will have to pay normal NHS charges. All patients are first screened by a Senior Clinical Teacher in order to allow the allocation of suitable patients to the different year groups. The patients are asked to give anonymized feedback after each course of treatment and this is given as formative feedback to the students.
The second and subsequent years
From the start of their second year the students are based full-time at the DECs, returning to Preston twice per term for further clinical skills courses. All other teaching is done at the DEC with the DEC-based Senior Clinical Teachers providing tutorials and facilitating the Problem Based Learning elements of the course. The School has invested heavily in state-of-the-art videoconference equipment which allows lectures to be delivered from Preston to the DECs. The students can see and interact with the lecturer and with their peers in the other centres. All the lectures are recorded and placed on the ‘Blackboard’, the University's e-learning environment.
In the third year of the course the students continue their clinical activity at the DEC and start their secondary care placements. These take place at the General Hospitals in the areas of the DECs and continue into the final year of the course.
From the May of the third year, the students also spend 1.5 days a week at their ‘Enhanced Training Practices’ (Figure 3). These are general dental practices which were commissioned to improve access in the local area. Each practice has four surgeries for the senior students to work in: each student is supported by his/her own nurse and is responsible for the appointment book just as he/she will be in the Foundation Year. Each practice also employs a clinical supervisor who is responsible for four students and there is a lighter level of supervision than there would be in the DEC.
Challenges and opportunities
Change from typical student life style
The student numbers at UCLan are small compared with the traditional school and each cohort is then divided into four with a maximum of 24 students across the year groups in each DEC. The students have to adapt to the change from the normal student lifestyle with the added constraint, often of living full-time in the same area as the DEC staff and patients.
Over the 5 years that the DECs have been running, the students have developed a well-established buddy system within each DEC, which means that, by the time the new students start full-time at their allocated DEC, they already feel part of a lively social group.
Learning to work as part of the dental team
At the DECs the students work within a close team of DCPs and receptionists. The nurses and receptionists have a role in their training and assessment and, with such small numbers, mistakes are not easily hidden. The students rapidly learn the importance of being good team members.
Knowing your students too well?
Small numbers also mean that the teaching staff get to know the students well. This has advantages as well as disadvantages. On the one hand, the struggling student is easily spotted and an action plan can be speedily put in place, on the other hand, any conflict can seem much more obvious in a small cohort.
However, overall the students seem to enjoy the course as the GDC noted ‘The students’ enthusiasm for the training model at UCLan and the level of support they received from clinical staff throughout their course was striking.’
The challenges of quality assurance and consistency
The Clinical Co-ordinator is responsible for ensuring communication between the DECs and the Clinical Skills Team based at Preston. The Senior Clinical Teachers have regular meetings with their DEC. The Secondary Care Consultants from all four areas also meet with the Course Team on a regular basis. There are regular training meetings at Preston to which all the supervisors are invited. Discussion of marking criteria and calibration of assessors are standing items on the agenda at these meetings.
The dental school at UCLan does not subscribe to the concept of requirements but wishes to ensure that students receive a broad experience and are able to demonstrate appropriate standards. It uses the term ‘targets’ rather than ‘requirements’: a target is something to aim at rather than being an all-or-nothing figure. It has developed its own online ‘Leopard’ system for recording the grades of all clinical activities, which allow comparison of consistency of grading across all sites. The pattern for individual assessors can also be reviewed.
Professor Lawrence Mair, the founding director of the course, commented to the GDC inspection team ‘There is no more difference in experience of students between the DECs than there is between students in a DEC.’
There is verbal feedback from some Foundation Trainers that UCLan students have good levels of clinical ability which are allied to high levels of maturity. The latter is not surprising given that they have completed a graduate entry programme. Their clinical abilities may also relate, in part, to their being slightly older than their counterparts in other schools. However, it may also reflect the benefits of their predominantly primary care education, coupled with their providing whole patient care over the three years that they spend in their DEC. The students gain a high level of clinical experience, which records indicate have remained relatively constant over a four-year period, as illustrated in Figure 4.
Future plans
The Dental School at UCLan owes a great deal to its first Head of School, Lawrence Mair, for the determined and, in many ways, brave way in which he oversaw the establishment of this new model of dental school. However, he benefited from the work of many colleagues on the staff of the school, most of whom did not have a traditional academic or NHS secondary care background but who, by dint of effort and initiative, have made it innovative and successful with its focus on primary dental care.
The premise for establishing UCLan, and indeed the Peninsula, was to locate dental schools in areas of England where there was a shortage of dentists. Whether this premise will be validated by the UCLan graduates settling in the North-West of England remains to be seen. This is the subject of current research between the School of Medicine and Dentistry at UCLan and the Postgraduate Dental Dean at Health Education England North-West England.
Conclusions
The first seven years of the graduate-entry BDS degree programme at UCLan have been both innovative and exciting. The students themselves have enjoyed the experience. Where these early career colleagues ultimately will work as dentists is not entirely clear, but there is already clear evidence that a high-quality Bachelor of Dental Surgery Degree can be delivered when the overwhelming majority of a student's clinical experience is gained within a primary dental care setting.