Interprofessional collaboration on oral health for frail home-dwelling older people: a focus group study on needs and barriers experienced by general practitioners and community pharmacists | BMC Primary Care

Seven focus groups were conducted, comprising five with GPs and two with pharmacists, involving a total of 51 participants. The decision to conduct additional focus groups with GPs was based on the feeling that new themes still emerged after three focus groups, unlike with pharmacists, where little new information appeared after two sessions. There were also more disagreements among GPs, while pharmacists seemed more aligned. It should be noted that this is an inherently subjective process that requires interpretation, and there is always potential for new insights [53].

The average sample size per focus group was seven participants, with a minimum of four and a maximum of ten. The average duration of the focus groups was 90 min. Six were conducted in person, while one was held via MS Teams due to the participants’ demanding work schedules posing challenges for in-person meetings. Table 1 provides a summary of the demographic profiles of the participants.

The work characteristics of the participants were also assessed. Among the 40 GPs, the majority were employed in monodisciplinary group practices (n = 19), followed by those in a multidisciplinary group practices (n = 11). Additionally, eight GPs operated solo practices, while two combined one these roles with work in a residential home. Among the 11 pharmacists, the majority were owners of independent pharmacies (n = 8), with one participant employed in an independent pharmacy and two in pharmacies affiliated with larger organisations.

Thematic analysis identified four main themes and various subthemes regarding the needs and barriers to interprofessional communication and collaboration on oral health in FHOP. The main themes were (1) engagement of GPs and pharmacists in oral health, (2) professional relationships between OHPs and both GPs and pharmacists, (3) information exchange on oral health, and (4) accessibility of OHPs. The main themes seemed interrelated, as illustrated in the causal loop diagram in Fig. 1. A summary of the main themes, subthemes, and topics, including illustrative quotes, can be found in Table 2 at the end of this results section.

Theme 1: Engagement of GPs and pharmacists in oral health

The engagement of GPs and pharmacists in oral health was identified as a first prominent theme. Many participants questioned how collaboration on oral health could occur if they were not currently paying attention to it. Figure 2 at the end of this theme illustrates a causal loop diagram depicting the various factors influencing the engagement of GPs and pharmacists.

Current situation

Both GPs and pharmacists reported paying minimal attention to the oral health of frail home-dwelling older people when they had no complaints. Many GPs did not routinely discuss dental visits, nor did they perform preventive oral examinations. Both GPs and pharmacists admitted that they seldom initiated conversations about oral health.

GP22: “I think that most general practitioners do not have the reflex to focus on teeth. Did we cover that in our training? No. Are we likely to pay attention to it? I don’t think so.”

Pharmacist09: “We might address other topics more quickly, because we might see them as potentially more dangerous… Oral health often seems less urgent than something else…”.

In patients with specific health conditions (e.g. diabetes) or symptoms (such as toothache or difficulties in eating), many GPs indicated performing oral examinations or advising dental visits. Some pharmacists recognised the need to pay more attention to oral health when observing frequent purchases of products such as mouthwash or adhesive pastes, but they acknowledged that they rarely did so.

Pharmacist09: “There are quite a few older patients who constantly ask for a bottle of mouthwash… perhaps we should address that more and engage in conversation. I think we don’t do that enough; at least, I don’t.”

When FHOP reported oral health issues, GPs typically investigated potential medical causes and initiated treatment if necessary. Both GPs and pharmacists generally referred FHOP to OHPs for oral health problems. However, due to limited accessibility of OHPs, some pharmacists reported a tendency to refer patients to GPs instead. GPs frequently had to prescribe antibiotics for temporary pain relief. Both GPs and pharmacists indicated that they occasionally made exceptions for FHOP compared to other patients by attempting to arrange appointments with OHPs, although they were less inclined to do so due to previous negative experiences.

Pharmacist 10: “We are more likely to refer patients to GPs rather than to the dentist; they are much easier to reach, and otherwise, patients in pain would have to wait for weeks or maybe months”.

GP21: “If you try to make an appointment for them, you have to call five or six dental practices, only to be told every time that there is no availability. And when you finally manage to get an appointment, the patient says: Oh no, my daughter can’t take me then.”

Barriers, needs and facilitators for engaging in oral health

GPs’ and pharmacists’ perceptions regarding FHOP and oral health

Many GPs and pharmacists reported paying minimal attention to oral health in FHOP, believing it was not a priority for this patient group. Several participants highlighted that FHOP often had other medical issues requiring more urgent attention. Furthermore, they noted that minimal emphasis had been placed on the importance of daily oral hygiene and preventive dental visits during the upbringing of this generation. Additionally, some GPs and pharmacists believed many FHOP feared the pain associated with dental appointments.

CP02: “38: “I think those people often have many other medical problems on their minds that are far more urgent than their oral health…”.

GP11: “I believe that in this generation, dental care was less embedded than in ours. Those now in their 70 s or 80 s tended to visit the dentist only when there was a problem.”

Moreover, many GPs and pharmacists expressed the belief that even if accessibility of OHPs were to improve, particularly the oldest FHOP would still refrain from seeking dental care. They indicated that FHOP were unlikely to visit OHPs or change their oral health routines, making it seem a waste of time to focus on oral health if FHOP did not express any complaints.

GP29: “Those older people we’re talking about, in my opinion, are a lost cause when it comes to oral health. We can advise them, but if they don’t want to go, forget it. We invest our time, but time is money as well, you know.”

Both GPs and pharmacists suggested various methods for raising awareness among FHOP but immediately noted the challenges in reaching the oldest FHOP with prevention efforts. Many participants believed engaging FHOP in oral health was particularly difficult due to the numerous perceived barriers.

GP30: “You won’t be able to engage frail older people in oral health prevention. We’re talking about a group you can’t be made aware of other issues either”.

Responsibility of GPs and pharmacists in oral health

Many GPs and pharmacists also acknowledged that they did not feel responsible for oral health, believing it to be the responsibility of OHPs. They also indicated that they felt less responsible for oral health due to their lack of knowledge in this area, highlighting a need for further training to increase their confidence in identifying and referring oral health issues.

GP20: “We can handle acute issues, and that’s part of our role, but prevention in oral health should be the dentist’s responsibility, and this responsibility shouldn’t rest with us”.

Pharmacist 11: “I think oral health is not a priority for us because we lack sufficient knowledge about it.”

GP03: “If you don’t have much knowledge, you’re not likely to ask questions… When patients ask you something and you have to say you don’t know, that’s not great”.

Some GPs also cited the limited accessibility of OHPs as a reason for feeling less responsible for oral health. Many GPs indicated they were very accessible in terms of availability and affordability, leading FHOP to seek assistance from them for oral health issues. Some pharmacists also tended to refer patients to GPs instead of OHPs. This situation resulted in GPs feeling overwhelmed by the additional workload and the need to prescribe antibiotics against guidelines for temporary pain relief. These frustrations led some GPs to feel entirely disengaged from oral health responsibilities, believing OHPs should take full responsibility for this aspect of patient care. Thus, many GPs and pharmacists emphasised the necessity of improved accessibility, questioning the value of encouraging this target group to seek dental care when they foresee access barriers.

Pharmacist 05: “Dentists are seriously understaffed, but we still want to activate those older people to go to the dentist. Then, we at least need to make sure they have somewhere to go.”

Furthermore, some GPs and pharmacists mentioned feeling less responsible due to (1) the lack of guidelines regarding oral health for them and (2) their belief that FHOP do not expect any action from them concerning oral health.

GP02: “The only guideline I find is that I’m not allowed to prescribe antibiotics for an abscess. One guideline for GPs, that’s it…”.

Pharmacist 06: “I don’t think that patients expect further action from us. They’ve received their antibiotics, the abscess and the pain will go away, so they are satisfied.”

Recognition of the role of GPs and pharmacists in the oral health of FHOP

Conversely, many GPs and pharmacists recognised the importance of oral health for the overall health and well-being of FHOP, prompting them to acknowledge that they should engage more in oral health. Despite some discussion among GPs regarding their role, most GPs and nearly all pharmacists ultimately acknowledged their potential role in the prevention, identification, and referral of oral health issues, particularly since many FHOP who visit the GPs or pharmacists might not access dental care. Many participants emphasised, however, the necessity for additional knowledge to fulfil this role effectively. Some GPs were convinced that a motivational conversation between the FHOP and their GP would have a greater impact than traditional campaigns. However, other GPs remained convinced that the responsibility lies within FHOP, their informal caregivers, and OHPs.

Pharmacist 03: “We could play a larger role in monitoring oral health and in motivating and encouraging them [FHOP]. However, we need to be informed; if we don’t know anything, we can’t do much.”

GP03: “I believe there is a role for us in preventive care. At the very least, we should ask them if they visit the dentist once a year.”

Other factors influencing the engagement of GPs and pharmacists in oral health

Many GPs and pharmacists identified a lack of time as a significant barrier to addressing oral health in FHOP, who often present with multiple, more urgent complaints during a single consultation.

Pharmacist 09: “I believe it often comes down to a lack of time… they usually come to us with problems that seem more urgent than oral health…”.

GP04: “Often, there is simply not enough time during a consultation. Frail older people arrive with five complaints at once, and addressing those in fifteen minutes is challenging enough.”

Consequently, GPs highlighted the need for increased resources for prevention, which could facilitate a greater focus on oral health.

GP21: “I think to be honest that the way our system is set up doesn’t allow for preventive work right now because we’re already swamped with reactive work. Plus, there’s no funding for prevention either.”

Additionally, some GPs and pharmacists found it challenging to initiate conversations about oral health without a clear prompt, perceiving it as a sensitive topic. Several participants believed that FHOP may feel embarrassed to address their oral health problems. A few pharmacists added that this hesitation to initiate the conversation was further reinforced by their fear of leading FHOP into lengthy and costly dental treatment pathways.

GP34: “When a patient opens his mouth and you see really poor oral hygiene, it’s a bit awkward to say “I can see you have bad oral hygiene, you should go see a dentist”. Especially when they came to see you for something else.”

Pharmacist 01: “I think oral health is an important topic, but for me, it’s not always the easiest one to bring up. I think it’s about the shame that the patient might feel. They [FHOP] also don’t tend to bring up their oral health issues themselves.”

Furthermore, many GPs and pharmacists highlighted the necessity of information exchange on oral health between OHPs and primary care professionals to effectively engage with FHOP’s oral health (see theme 3).

Theme 2: Professional relationships between OHPs and both GPs and pharmacists

The professional relationships between OHPs and both GPs and pharmacists were identified as a second recurring theme across the focus groups. Many GPs and pharmacists reported that they did not perceive primary care OHPs as members of their professional network, which hindered information exchange and collaboration. Additionally, the limited accessibility of OHPs, along with the resulting frustrations among GPs, further complicated these professional dynamics. Some pharmacists noted that they are less familiar with patients’ OHPs, as individuals often travel further to find an OHP who still accepts new patients. Moreover, some participants indicated that OHPs tended to engage less with other professionals groups compared to other primary care professionals.

GP37: “From our perspective, dentists aren’t really part of the landscape with our fellow medical colleagues.”

Some GPs indicated that their frustrations towards OHPs contributed to a diminished sense of responsibility, resulting in lower engagement in oral health. GPs and pharmacists added that not knowing OHPs acted as a barrier to effective information exchange.

To improve professional relationships with OHPs, many pharmacists and some GPs suggested local introductions or interprofessional trainings to enhance mutual understanding of each other’s roles and perspectives regarding oral health. A few GPs emphasised that clear interprofessional agreements could facilitate smoother collaboration, citing successful collaboration with dermatologists, despite having similar waiting times to OHPS. However, other GPs expressed a lack of interest in further engagement with OHPs.

GP04: “If we could meet and get to know each other a little bit, it would make it easier to pick up the phone. Right now, you don’t know who you’re speaking to, and that makes it more difficult.”

GP33: “We’re not asking for more contact with dentists. It’s a separate world for us.”

Theme 3: Exchanging information on oral health

Current situation

A third theme was the necessity for information exchange to facilitate effective collaboration on oral health. Many GPs and pharmacists indicated that, aside from necessary referrals, communication regarding oral health was very rare.

The oral health-related patient information received by GPs and pharmacists primarily originated from FHOP themselves. Many GPs noted they did not receive reports about dental visits from primary care OHPs, unlike secondary OHPs, from whom they did receive such reports. Furthermore, GPs indicated that oral health rarely emerged as a topic in multidisciplinary consultations, and OHPs were seldom included in these discussions. While many GPs often exchanged patient information with home care nurses, this rarely pertained to oral health. Moreover, nearly all pharmacists highlighted their inability to access patient information online. Some GPs and pharmacists emphasised that they are often unaware of the oral health status of FHOP, as older people are not inclined to share this information with them.

GP09: “Without a report, you have to rely on what patients tell you, which means you miss a lot of important information and you can’t help them retrieve it. This patient group often only understands half of what OHPs are telling them.”

When patient information concerning the oral health of FHOP was shared, it was usually initiated by the GP. A few GPs indicated that they were occasionally contacted by OHPs to discuss medication prior to dental treatments.

When seeking information on oral health, many GPs and pharmacists were more inclined to use online search engines like Google rather than consulting local OHPs. Some pharmacists added that much of the information they received was heavily influenced by commercial interests. Many participants acknowledged that while medical-pharmaceutical meetings often occurred where various topics were discussed, oral health was never one of them, and primary care OHPs were never involved.

Needs & barriers for exchanging information

To enhance communication and collaboration regarding oral health, GPs and pharmacists stressed the necessity for a communication platform that would facilitate the exchange of patient information with OHPs and other primary care professionals. Many pharmacists reported a lack of access to existing communication platforms, and both GPs and pharmacists believed that OHPs faced similar limitations. Pharmacists highlighted the importance of access to these platforms and expressed a willingness to share medication information to alleviate the burden on busy GPs.

Pharmacist 05: “Once we have that platform, we might be able to communicate better, and we could also follow up on the oral health of these patients, have they been seeing a dentist, what has been done so far,…”.

When asked about the information needed for effective collaboration on oral health, many GPs and some pharmacists indicated a desire for alerts when FHOP had not visited an OHP for several years. This is particularly important for FHOP who are not actively engaged in the oral health system, as it presents an opportunity to initiate discussions about their oral health. In addition, many GPs and pharmacists underscored the vital role of home care providers. Their frequent and prolonged interactions with FHOP enable them to identify oral health issues at an earlier stage and notify GPs. Additionally, some GPs and pharmacists called for guidelines regarding brief reports following FHOPs’ visits to OHPs, especially after referrals, to improve follow-up on FHOP’s oral health, as they questioned the completeness and reliability of information provided by FHOP after dental visits.

GP11: “Actually, health insurance funds should check who hasn’t been to the dentist in a while and then a warning should appear in our patient records. That would make it much easier to follow up and start the conversation.”

CP04: “I think we should definitely also consider home nurses, because they are often much closer to this patient group….”

In contrast, some GPs who had previously expressed significant frustrations with OHPs and did not feel responsible for oral health indicated that they did not find this necessary, citing the already overwhelming volume of reports from various healthcare professionals.

GP27: “We’re already overwhelmed with a massive number of reports. […] What can they send that would actually be relevant to us?”

Nevertheless, many GPs and pharmacists noted that knowing OHPs and cultivating a good professional relationship would ensure smoother information exchange.

GP04: “If we could meet and get to know each other a little bit, it would make it a lot easier to pick up the phone.”

Theme 4: Accessibility of OHPs

Many GPs and pharmacists identified limited access to oral health care as a significant barrier to interprofessional collaboration on oral health for FHOP. The majority of the participants noted that it is generally difficult to find an available dentist when needed. For this patient group, however, access to dental care was even more challenging, as they often lacked a regular dentist. Consequently, many OHPs refused to accept them as patients, having reached their capacity and not accepting new ones. Additionally, mobility issues and physical problems among FHOP, along with doubts about the affordability of dental care – shared by both FHOP and participants – further contributed to this issue.

GP27: “For people who don’t visit the dentist regularly, it’s really hard to get an appointment with the current patient stops…”.

Pharmacist 11: “They [FHOP] are especially worried about the costs, as they really don’t know what they will have to pay.”

Participants offered various suggestions to address these problems. First, many participants emphasised the need to address the shortage of dentists. Second, tasks that do not necessarily require a dentist’s expertise should be delegated to dental hygienists. Third, some GPs suggested that OHPs reserve slots for emergencies, and not just for regular patients. Fourth, GPs and pharmacists indicated that oral health care should be affordable and that greater transparency regarding costs is essential so that primary care professionals can clarify misunderstandings about costs. Finally, many participants noted the need to explore strategies to overcome mobility barriers for this target group, including home visits by OHPs, the regular presence of OHPs at local service centres, and the inclusion of OHPs in multidisciplinary practices.

Pharmacist 06: “More dentists, that’s something we all dream of.”

GP13: “The question is, can’t preventive oral care be provided by someone other than the dentist?”

GP23: “They [dental hygienists] could visit people at home and carry out an initial screening to assess whether it is necessary to travel to the dentist. Everything okay? Great, then the next visit is in six months.”