Understanding referral behaviours in Oral Surgery in England - a mixed methods study.

Aim
This thesis investigates the referral behaviours of General Dental Practitioners (GDPs) in England for patients requiring oral surgery, addressing a critical gap in understanding the behavioural, systematic and contextual drivers underpinning referral decision making.

Existing Literature
Existing literature demonstrates limited UK-specific evidence and a lack of qualitative insight into psychosocial influences such as clinician confidence, training, access to services, perceived risk, and medico-legal concerns. Current initiatives, such as managed clinical networks (MCNs) and categorisation of levels of care focus on triage and care closer to home but fail to address why GDPs are increasing their referrals in Oral Surgery.

Method & Results
An explanatory sequential mixed-methods approach was employed. The quantitative phase analyses of 98,671 referrals from the West Yorkshire Managed Clinical Network (2016-2019), alongside a national dataset of 1.75 million referrals during the COVID-19 period (2019 to 2021). Exodontia accounted for over 60% of referrals. Referral activity was highly concentrated, with 10% of GDPs responsible for 60% of total referrals. Following an initial pandemic related decline, referral rates surged leaking at 8.5 times pre-pandemic levels.

The qualitative phase, informed by the COM-B model (Capability, Opportunity, Motivation – Behaviour) utilised semi-structured interviews with GDPs and focus groups with Foundation Trainers to explore determinants underlying these patterns.
Confidence emerged as the central mediator of referral behaviour, influenced by variability in undergraduate oral surgery training, the transition from supervised to independent practice and access to ongoing support.
Structural factors, including the financial constraints of the NHS UDA contract limited the feasibility of providing complex oral surgery in primary care. Additionally, perceived risk especially from fear of complications and litgation acted as a significant driver of referral decisions.

Integration of these findings provides an insight in the behavioural understanding of GDP referral behaviours.

Conclusion
This thesis proposes a multi-level intervention framework targeting education, system design and policy reform, including standardisation of surgical trainig, enhanced feedback mechanisms between primary and secondary care and reconsideration of contractual incentives.
These findings offer important implications for optimising referral pathways, supporting the primary care workforce and improving patient access and outcomes in oral surgery services.