Table 1 Key elements of the IPP programme organised according to CATWOE

C: beneficiaries of the IPP programme

The key beneficiaries of the IPP programme were young children in the region with high levels of dental caries

The NHS dental practices that worked within the 'flexible commissioning' approach

A: roles and functions in IPP

The Local Dental Network (LDN) was considered to be a key driver for IPP, who were seen as the 'movers and shakers' within local professional circles and so had roles as 'clinical leaders'

NHS England were responsible for local commissioning and so were pivotal to the success of the programme and the underpinning 'flexible commissioning' approach

Public Health England (PHE) leadership was also seen as critical to ensure a dental public health approach was taken to address the problem

The LDN and PHE had developed a business case to take to the NHS England, so multi-agency working was seen as key at a strategic level

The engagement of General Dental Practitioners (GDPs) and local dental teams was seen as pivotal (and the incentives and leadership skills needed to promote change at a practice level)

Given the change to the 'traditional' commissioning model, the IPP programme had 'national eyes' on the project and so an on-going relationship with the Department of Health was key

Members of the dental team (dental practice owners, dental care professionals, dental nurses and dental receptionists) were seen as critical to the delivery of IPP

T: changes and adjustments to implement IPP

Multi-agency and cross-sector working were critical

IPP was seen to be 'over and above' what GDPs were normally commissioned to provide, so clinical leadership, culture and behaviour change was key (for example, preparedness to change appointment times to facilitate after-school appointments and increase appointment times)

Incentives under-pinned the delivery of the programme

GDPs and dental teams needed to understand the problem from a public health perspective (that is, widen their frame of reference and become more 'community-facing')

The whole practice team had to engage with the programme (and sometimes there was dissonance between practice owners and their teams, who would deliver IPP)

Identification of 'movers and shakers' within the professional was important to promote peer-to-peer acceptance of the programme

Addressing NHS England's concern about the impact of the programme on patient charge revenue (PCR) was important

In turn, this meant re-focusing NHSE's priority on promoting access to services

There was a need to focus on evidence-based prevention and health promotion

To facilitate the latter, influencing the attitudes of patients and their families was key

W: underlying context for IPP

IPP to be delivered by dental teams while still working to the existing NHS dental contract (which set targets for activity and performance

Availability of suitable appointments for the programme would require a change in the mind-set of the practice and dental receptionists

Given this, a change in practice culture was considered to be key

The LDN were keen to ensure that the programme was delivered to a consistent standard

Given the novelty of the 'flexible commissioning' model, there was a need for the LDN to challenge traditional methods of service provision and challenge national priorities (access/PCR)

This required NHSE dental commissioners to allow 'top-slicing' to support IPP

National programmes ('Starting Well'; 'Dental Check By One') were also starting to be delivered across England, which could be an alternative to the programme or subsumed into it

PHE were driven by the local needs of the population and the need to reduce dental caries among young children

At a practice level, different members of the dental team held different world-views about their role

O: factors that influence the ownership of IPP

Elements that determined the success of the programme were identified in the transformations section, but the two key factors that were considered to be critical was the top-level 'buy-in' among the different agencies and the clinical leadership to deliver the programme, through the LDN and the local dental teams in the region

E: contextual barriers

Supportive dental practice owners were needed in order to change current working practices

DCPs were to run the programme, who had a different 'world view' to their practice owners

Education of the DCPs was fundamental to the implementation of IPP and the consistency of its delivery (this included training of dental nurses in the application of fluoride)

A number of specific practice-level barriers were articulated (for example, physical surgery space, capacity within the workforce, willingness to problem solve and the headspace to do this, given the confines of the existing NHS dental contract)

Funding of training was not guaranteed (achieved initially through the 'claw-back' mechanism following annual reviews of dental contracts)

Practice reorganisation was required to promote role-substitution and role-supplementation (greater use of 'skill mix' in the programme)

Changes to internal pay structures within the practice to deliver the programme (and the problems caused if other members of the team on the same pay structures were not involved)

Geographical location of practices also posed a potential barrier to the training of dental nurses (who also required time away from the practice or their 'own-time')

National priorities on improving access and reducing changes to PCR