The performance of primary care trusts (PCTs) is assessed through the NATPaCT competency framework.¹ Criteria for service provision include a section on equality and diversity. PCTs are required to monitor the uptake of services by ethnic minorities; to show development of patient-centred services which are culturally sensitive and planned in partnership with local people; to show understanding and implementation of guidelines to encourage diversity; to provide access to interpreters, and to train and educate staff in diversity awareness.

Access to, and the ease of use of health services, is an important potential source of inequality in the health experience of different ethnic groups in Britain. If such inequalities do exist, they may have important influences on both the quality of care received and the outcomes of that care.²

Eleven per cent of Oldham's population is Asian.³ The town has particularly large Pakistani and Bangladeshi communities, mainly living around the town centre in areas of socio-economic deprivation. Young children from these communities suffer much higher levels of dental caries than the white population. In some of the predominantly Asian schools, caries prevalence in 5-year-olds is 90%, with an average of six teeth affected.⁴ Neighbouring Tameside also has significant Bangladeshi and Pakistani populations with poor oral health in 5-year-olds.

Dentists working in the areas reported that they regularly had problems communicating with non-English speaking Asian patients. Language problems affected their ability to make a diagnosis or communicate their treatment plans, instructions or preventive advice. Pakistani and Bangladeshis reported that communication difficulties made them less likely to attend the dentist.

Historically the areas have had few Bangladeshi or Pakistani dental nurses relative to the size of the local populations. The problem was at the recruitment stage - young women from these communities were simply not applying for the posts. It was suggested the problem was cultural - that nursing was not seen as a desirable profession for Asian women. In fact Muslim women may be reluctant to enter general nursing through apprehension about nursing male patients.⁵ However dental nursing does not involve intimate contact with patients and dental nurses are rarely unchaperoned with male patients. The real problem seemed to be a lack of role models: it did not occur to Pakistani and Bangladeshi women to enter dental nursing. It was clear that established recruitment methods were unlikely to change the situation and that what was indicated was active recruitment from these populations.

For Oldham and Tameside's primary dental care services, recruiting more Pakistanis and Bangladeshis was a clear priority. A scheme to recruit members of the local Asian communities into primary dental care services should make local dental services more representative of the populations they serve, and has facilitated communication with client groups who suffer some of the worst dental health in England.

An innovative scheme was designed and first implemented in 1999, supported by development funding from West Pennine Health Authority. The scheme involved the creation of three 2-year dental nurse traineeships for fluent Bangla/English and Punjabi/English speakers. The aims of the scheme were to:

• Increase capacity within local Pakistani and Bangladeshi communities, improve understanding of oral health and oral care issues, and promote employment-related skills.
• Make local primary dental care services more representative of the populations they serve.
• Improve accessibility and appropriateness of dental services for ethnic minorities.
• Improve communication between the primary dental care team and patient concerning symptoms, diagnosis, treatment planning, medical history and prevention.

It was anticipated that improvements in communication, accessibility and appropriateness would be achieved directly through the trainees interpreting skills and indirectly through increased awareness and understanding of Pakistani and Bangladeshi culture among the dental team.

The first three trainees were recruited into the community dental service, where they had a dual role as both dental nurses and interpreters for other team members. They contributed to the work of oral health promotion, epidemiology and special needs teams and undertook month-long placements in general dental practices. They received on-the-job training and support to study for the dental nurse certificate.

The scheme was considered successful and in 2001 was expanded. However a number of lessons were learnt from the experience of piloting the first scheme. Attracting high calibre applicants was fundamental to the success of the scheme. Advertisements in the Asian press and Job Centres were only part of a successful recruitment strategy. The Careers Service, now known as Connexions⁶ was an important source of good candidates, and advertisements were placed in community centres, with projects in Asian areas and in local colleges.

Once the first trainees had completed their contract they took part in a review of the scheme, along with qualified staff. The scheme had not been without its difficulties. The trainees had come into a service which had up until that point employed only qualified and relatively mature staff. The trainees were young people in their first employment or training post, and this inevitably brought a number of challenges for their managers. Furthermore it was the first time that existing staff had been exposed to the very different norms and values of the extremely traditional local Muslim communities. A number of issues arose over gender roles and marriage arrangements which gave existing staff valuable insights into the communities they were serving.

Despite the issues that the scheme raised, trainees and staff had all found the scheme worthwhile. Improvements were suggested from both sides in communication and in the structuring of the training. The trainees worked closely with many different members of staff, therefore a log of competencies was developed so that everyone was clear about what the trainees could do already and what they needed to learn under supervision. This was important within the community dental service but became vital as the scheme spread into general dental practice and into the hospital dental service. Representatives of each part of the service defined the skills that the trainees were expected to attain, and these were brought together in a personal training record, not unlike that now used for NVQ training.⁷ Accountability for completing the record was clarified, and training supervisors designated.

With the support of Oldham primary care group the scheme was expanded to employ two further trainees to work in Oldham general dental practices. Dentists from six town centre practices were consulted. All were supportive of the principle of the scheme. They all stated that they would be prepared to offer placements to trainees. They expressed a willingness to allow trainees to have on-the-job experience including chair-side work, reception work and giving dental health education, all under the supervision of a member of the general dental practice team.

The dentists saw their participation as a gesture of support for the scheme, rather than an opportunity to exploit free labour. They were clear that there were costs to accommodating a trainee, and felt that the success of the scheme would depend on the calibre of the trainees. Careful recruitment was considered crucial.

A co-ordinator was designated to liaise with the practices. They communicate with both the practices and the trainees and look for solutions if any problems arise. A member of staff was designated for each practice to fill in the log and to work with the co-ordinator. The dentists themselves provide regular feedback and evaluation of the scheme, closely linked to completion of the competencies log. The practices made the commitment to provide training, monitoring and support. At times this needed tactful handling: as general dental practices are very individual different practice policies had to be accommodated to meet training needs.⁸

Active recruitment measures, already described, have produced a high standard of applicant for advertised posts. Induction for these trainees is provided by the local salaried primary dental care services over a period of a month. Initial training covers conformance to working policies and procedures, background knowledge and basic skills. These include confidentiality, record keeping, charting, health and safety, care of equipment, mixing, communication skills, the role of the different parts of primary and secondary dental care services and causes and prevention of dental disease. The trainees undertake college-based training towards the NVQ 2 and then the NVQ 3 in dental nursing.

The schemes have proved successful and popular with patients, dental staff and trainees alike. Nine trainees have so far been recruited to the scheme, of who three are currently in training, three are now working in local dental practices, two are working for local health services and one left to raise her family.

The scheme has improved accessibility and appropriateness of primary dental care services for ethnic minorities, and communication between the practice team and patients. Patients and parents with little English exhibit a dramatic increase in confidence as soon as they understand what treatment is suggested, and become active participants in the process, questioning and resolving doubts and reservations. The dentists use the trainees routinely to assist in checking medical histories, explain treatment plans, give advice and instructions and to interpret generally.

The scheme has addressed a number of the NatPaCT competencies in equality and diversity in service provision. Services have become more patient-centred and culturally sensitive. As well as providing dental health materials in different languages, Tameside and Oldham's dental services are able to offer interpreting - not by a link worker or interpreter, but by a member of the dental team with the necessary knowledge and understanding of oral health and oral care. Awareness of diversity issues has improved immeasurably as English dental staff work side by side with Pakistani and Bangladeshi colleagues, building the team's awareness of the needs of the local communities.

The scheme has produced a radical improvement in the dental team's understanding of Muslim culture and religion. For example the significance of Ramadan, Hajj and the two Eids are now appreciated by the English staff in primary dental care services. Above all the trainees have become valued colleagues. This is particularly important in a town like Oldham, which gained notoriety 2 years ago for racially motivated disturbances. The Independent Report⁹ into the causes of the disturbances highlighted a segregation of the town's Asian and white populations as being the root cause of the unrest. Both management and staff in Oldham salaried dental services have become aware of the complexities of the issues affecting their colleagues from local Pakistani and Bangladeshi communities.

The scheme has also been successful in improving the capacity of Oldham's Pakistani and Bangladeshi community to understand oral health and oral care issues and to promote employment-related skills. Past and present trainees report an increase in confidence, pride and satisfaction in their work and an increase in the opportunities available to them. In the words of one of the first trainees: 'It's a great stepping stone for someone who wants to improve their career. It's earned me lots of respect in my own community. Everyone has encouraged me to make something of myself, everyone I've worked with. And that's how I got my new job.'

The trainees are also making Oldham's primary dental care services more representative of the populations they serve. Current and former trainees are serving the community through their work in local primary care services. Staff recruited through the scheme provide the role models that were lacking in the past. Such role models will encourage members of local Pakistani and Bangladeshi communities to take up careers in primary dental care - meeting the needs of their communities and the needs of the dental team.

Primary dental care services in Oldham and Tameside offer a model which could be developed nationally, not only in dentistry, but also in the wider NHS. Such a method of developing members of local ethnic minority populations, if widely applied, could address NHS recruitment shortfalls as well as producing equality and diversity in the workforce.