In the UK, and other western societies, people are living longer lives with less acute infectious disease, but experiencing more long term degenerative conditions in later life. As a result, medical care is increasingly being focussed on managing chronic illness, rather than curative treatment; improving and maintaining quality of life is a key concern for health care provision. Further, ongoing medical and technological advances offer increasing possibilities for maintenance of health and quality of life. Although recent political debate has emphasised the need for the increased use of technologies in the delivery of health care services[1
], this must be considered within a context of a growing proportion of the population that might benefit from such treatments. This presents a problem for those responsible for delivering health care in a context of finite resources, and decisions must be made about how such resources should be allocated [3
]. In health care systems, like the NHS, which are based on the premise that health care should be free at the point of delivery, identifying ways of balancing the supply and demand of finite resources is becoming increasingly necessary [4
One mechanism of addressing finite resources is for patients to pay a contribution towards the cost of their treatment. Within this particular model of providing and financing health care it is useful to understand how clinical need and treatment decisions are negotiated. This is necessary for three reasons: Firstly, any rationing of services impacts on the everyday practice of health care professionals who must make decisions about the provision of services to individual patients using criteria which are beyond perceived clinical need, thereby according greater significance to non-clinical influences on decision-making [5
]. Secondly, patients themselves are faced with additional choices and decisions to make about treatments and services offered to them. They not only need to consider their perceived clinical need, but also any potential benefits to their quality of life, as well as assessing the value of such benefits if they as individual patients are required to make a part or whole contribution. Thirdly, resource rationing, and the increasing consideration required of non-medical decision making factors, has important implications for how clinical need
itself gets negotiated and reconfigured through the process of decision-making.
This study will use the provision of complete implant-supported overdentures (ISOD) as the vehicle to develop generically applicable insights into the processes of negotiating clinical need and making treatment decisions within a context of rationed resources. Implants are devices that can be placed directly into the bone of the jaws to replace lost teeth and/or provide support for dentures. They are highly effective as they stabilize the denture and allow much improved function. ISODs have been shown to improve patient satisfaction and edentulous patients' oral related quality of life in this clinical situation which can be regarded as a chronic disability or handicap [6
]. The physical impairment brought about by the loss of natural teeth represents a chronic disability because it negatively impacts on daily living activities, such as eating and speaking. A proportion of denture wearers may also be considered to be handicapped as they will actually avoid performing such activities in front of anyone outside close family members [9
]. ISODs are currently only available without charge through referral to secondary care. However, this option is only available to a very small proportion of these patients with very specific clinical needs. Within primary care dentistry, however, individuals are increasingly being able to choose implant treatment for which they incur a personal financial cost. Therefore this provides an excellent clinical setting which is constrained by finite resources in which to examine the process of patients and clinicians negotiating clinical need and treatment decisions.
Current evidence suggests that most edentulous patients would benefit from ISODs, and this form of treatment has been proposed by the McGill Consensus as the minimal standard of care [8
], however, there are not enough resources available to enable this. Within the current context there are two main groups who qualify for the provision of ISOD without incurring a personal financial cost within secondary care. The first is patients with severe denture intolerance including severe resorption of the lower jaw. These patients would normally be referred from their GDPs or from within the hospital. The second group comprises patients with apparently satisfactory anatomy but who find it more difficult than most to adapt to the limitations of complete dentures. Although it would be expected that secondary care provides implant treatment for those with the most marked problems, this is not necessarily the case. Those who receive such treatments may do so because of there being no available provision of ISODs within primary care in their locality, the referral patterns of their GDP or because they are more persistent in seeking a solution for their problems. Similarly, within primary care personal clinical experience suggests that people from a range of socio-economic backgrounds are willing to pay for ISOD.
Whilst the barriers to providing ISODs are not clear, they are likely to include the fact that, although an increasing number of GDPs have training and experience to carry out implant procedures, only a minority choose to do so. Compounding this issue is the fact that people now maintain natural teeth much longer, with the resultant effect being that the age at which people may become edentulous is rising. People in older age are likely to find adapting to dentures even more difficult and thus experience more problems which would be ameliorated by implants. Thus, the disparity between resources and demand for treatment services is increasing, and therefore a greater understanding of the processes of decision-making around treatment such as these that have personal cost implications, from the perspectives of both patients and dentists is required.
Finite health care resources have implications for practitioners and patients and also for how clinical need is determined and negotiated. Practitioners draw on a range of 'non-medical' factors in making decisions about how to treat their patients [5
]. Broadly, such factors have been characterised as relating to characteristics of the patient; characteristics of the clinician; and features of the practice setting[5
]. Demographic, socio-economic and social factors are known to be important in influencing treatment decisions made by health professionals. However, it has not yet been investigated how professionals' approaches to treatment decision-making may be affected by situations where the treatment option may incur personal financial costs for the patient. Limited existing research suggests that professionals themselves may adopt various strategies, including concentrating their discussions about possible treatments on those who are perceived to be able to afford to pay [3
]. Given the link between low-income and ill-health, this is unlikely to be a strategy which will meet all patient need and, indeed, may increase inequalities in health and access to health services[3
]. Questions also exist concerning how professionals make judgements and decisions about referrals to scarce secondary care resources, and what treatment options and choices to offer to which patients. In the context of dentistry, the day to day decisions made by GDPs have a significant influence on the oral health of the population [12
]. Whilst much previous research has concentrated on the influence of clinical factors on treatment decisions, it is increasingly acknowledged that factors such as the financial environment and patients' preferences might be expected to exert a major influence on dentists' decision making practices but are, as yet, poorly understood [13
]. In relation to ISODs, limited work in the area suggests that the relative influence of a range of factors (oral, medical and personal) on decision-making appears to vary greatly between different practitioner groups [15
]; this requires further investigation. Understanding the process by which health professionals, including dentists, make treatment decisions is becoming increasingly relevant in the context of increasing expectations of evidence based practice. Not only is it essential for dentists to consider the patient's values for alternative treatments and outcomes [16
] but it is also argued that dentists should combine the patient's treatment needs and preferences with the best available scientific evidence in conjunction with their own clinical expertise [17
As well as considering the implications for clinicians it is also important to note that the involvement and participation of patients, and the public generally, in decision-making about health care is a key priority in health policy [19
], which has attracted a substantive body of empirical research [21
]. Patients, and their roles in decision-making, have been conceptualised in various ways ranging from 'self-managers' [22
] to an increasing emphasis on the patient as a 'customer' [23
]. In reality however, such roles for patients are rarely realised [24
] and indeed patients may choose to adopt different 'roles' at different points within and without the clinical encounter. Clearly, in a health provision context where demand for services is increasing and resources are limited, patients themselves will be increasingly required to make decisions about treatments that involve additional personal costs to themselves, and which might bring considerable improvement to their quality of life and/or self esteem. Patient participation in decisions about dental treatments is beginning to attract empirical attention. Initial findings indicate that dental patients do have distinct preferences in relation to decision-making roles, and that these may not always be met in their interactions with their dentists [25
When making treatment decisions clinicians and patients must first determine clinical need. It is well recognised that social factors are particularly pertinent to practitioner-patient consultations [26
]. In dentistry, it is acknowledged that economic constraints may present problems for the definition and assessment of clinical need [27
]. It is argued that the assessment of need, and decision-making processes, should be considered on the three levels of the patient, dentists, and society. A key challenge for decision making around need in the context of dentistry is to establish the legitimate roles of these various parties, so that the concept of need can be used as a basis for planning and provision of services. Such goals would be advanced through a better understanding of how clinical need is defined and assessed by both patients and practitioners in decisions concerning treatments that have personal cost implications.
The benefits of a clearer understanding of negotiating clinical need and treatment decisions within the context of limited and finite resources is of interest to patients, purchasers and providers of health care services. At a national level, strategic planning and implementation of the delivery of a National Health Service is dependant on a full understanding of issues such as the uptake of care for the management of chronic conditions from the private sector. Those who commission the delivery of state funded health and social care (through Primary Care and Social Care Trusts), will need to devise strategies for delivering health services that reflect an understanding of decision making priorities and willingness to pay on the part of those who use them. Service providers (practitioners) themselves need to understand the complex, hitherto unexplored relationship between payment, effectiveness of treatment and demand in a health service which is increasingly a mix of public and privately funding. Those who insure patients against the costs of private treatment also have an interest in the process of decision making where a financial commitment is required.
This multi-disciplinary study will provide generically applicable and timely insights into an increasingly pertinent area of how clinical need and treatment decisions are negotiated within a context of finite resources. It will address this issue by examining in detail how, in a health care system with finite resources, clinical need and treatment decisions are mediated by perceived costs: physical, social, psychological and financial. Further, by addressing this neglected area of clinical research of interactions within dental consultations, it will develop new insights and understandings of the decision-making process within dentistry.