A Qualitative Evaluation of Patient Experiences of Receiving Endodontic Treatment Through the Sydney Local Health District Endodontic Access Scheme (SEAS)

A Qualitative Evaluation of Patient Experiences of Receiving Endodontic Treatment Through the Sydney Local Health District Endodontic Access Scheme (SEAS) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Qualitative Evaluation of Patient Experiences of Receiving Endodontic Treatment Through the Sydney Local Health District Endodontic Access Scheme (SEAS) Alexander C L Holden, Olivia Nova This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8154782/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background This evaluation examines patient experiences in relation to the Sydney Local Health District Endodontic Access Scheme (SEAS); an initiative run by Sydney Dental Hospital – a large tertiary referral centre in NSW. The purpose of this scheme was to enhance specialist services capacity by referring advanced endodontic cases to specialist endodontists and dentists with a special interest in endodontics practising in the private sector through a novel public-private partnership. Methods Patients who had received a voucher for private care through this scheme were invited to participate in an in-depth interview about their experiences. Following verbatim transcription, the data were qualitatively analysed. Through thematic analysis, iterative cycles of assessment led to the emergence of themes within the data. Results 12 participants agreed to be interviewed about their experiences on the scheme. Following iterative coding, five themes emerged from the data: 1) access and timeliness of care; 2) interpersonal quality and trust; 3) clinical outcomes and aftercare; 4) voucher design, policy, and continuity of care; and, 5) equity, quality, and trust in tertiary dental hospitals. Conclusion The analysis of the participants’ experiences demonstrates the ability the Sydney Local Health District Endodontic Access Scheme to address issues of access. Patients reported positive impacts on their quality of life and ability to retain function from being able to access complex endodontic care. The main area of dissatisfaction spoken about by those who had received an endodontic voucher related to the lack of integration and alignment in administration and management of the scheme between the public and private sectors. Participants who had received care through the scheme also spoke about the value of tertiary referral centres. It was specifically reported that the inconvenience of travelling to a large regional specialist centre was offset by increased trust and perceived quality compared to individual providers in private practice. Trial registration Not applicable endodontics dental access public-private partnership thematic analysis qualitative research Background The dental health of the eligible population of the State of NSW is provided for by the oral health services operated by NSW Health. Unlike other public health services which operate on an enviable provision of universal access, the NSW public oral health services operate on a basis of socioeconomic eligibility, which includes children under 18 with a Medicare card, and adults with certain Australian government concession cards [ 1 ]. The state provides a ‘safety net’ service for those who cannot afford to access care in the private sector where most of dental care is provided. For those who are eligible, the service is comprehensive, offering access to both general and specialist dental care based on prioritisation and assessed clinical need. For those who meet specific criteria for accessing different specialist services, the state offers access to all 13 specialist dental disciplines [ 2 ]. The specialist field of endodontics focuses on the management of the dental pulp, dental pain and the provision of root canal treatment. Sydney Dental Hospital (SDH) is one of two main tertiary dental referral services in NSW, but the only centre that accepts statewide referrals for endodontic care. In early 2021, SDH lost the only fulltime specialist endodontist working in the NSW public sector to retirement, with visiting dental officers (part time contracted specialists) then being completely relied upon for specialist workforce to provide endodontics. Despite multiple rounds of advertisement, SDH could not replace this lost specialist capacity. Shortly after, with 577 patients on SDH’s waiting list - which was further exacerbated by the impacts of the COVID 19 pandemic on public oral health activity - SDH had to cease accepting referrals for specialist endodontics. Elsewhere within NSW Health public oral health services, where clinical capacity is lacking, general dental services can refer to the private sector. This is facilitated through the Oral Health Fee For Service Scheme (OHFFSS) which issues paper vouchers to patients which allow them to seek specific treatments to a certain value from participating private practitioners [ 3 ]. While the OHFFSS supports access to emergency, general dental and denture treatment, access schemes have not had widespread application for specialist dental care. Due to having a high number of patients waiting for care and no other option within the NSW public oral health service, a decision was made to establish a specialist access scheme for endodontics the Sydney Local Health District Endodontic Access Scheme (SEAS). While the OHFFSS does accommodate the provision of root canal treatment, the financial amount provided would not satisfy the expectations of specialist or most general dentists with a special interest in Endodontics. In consultation with the state branch of the Australian Society of Endodontology, agreement was reached that fees would be set at the same quantum as the Department of Veteran’s Affairs dental fee schedule. Subsequent recruitment of private practitioners was conducted through an expression of interest promoted through the NSW branches of the Australian Dental Association and the Australian Society of Endodontology to identify suitable specialists and general dentists with advanced skills in endodontics. Prior to cases being referred to the private sector through SEAS, they were categorised for complexity using local criteria based on international standards and guidance [ 4 , 5 ], developed with input from the University of Sydney School of Dentistry. Practitioners who expressed interest in participating were asked to self-assess their capacity to manage moderately complex and complex endodontic cases based on the published criteria. A total of 22 general dentists with a special interest in endodontics and self-assessed advanced experience and 5 specialist endodontists were recruited from across NSW and ACT to accept referrals through the scheme. Following a process of being assessed through teledentistry, a total of 187 public patients received a voucher in 2022 to allow access to advanced care in the NSW private sector. This strategy allowed SDH to effectively manage demand for advanced endodontics care, alongside other activities to enhance specialist capacity such as establishing the Doctor of Clinical Dentistry training program in Endodontics in collaboration with the University of Sydney School of Dentistry. The SEAS initiative directly operationalises NSW Health’s Future Health: Strategic Framework 2022–2032, particularly through the goals of delivering safe care across all settings, partnering with consumers and ensuring equitable access [ 6 ]. By engaging extant private-sector infrastructure to address specialist workforce shortages, SEAS exemplifies the framework’s call for integrated, patient-centred care. Following the experiences of utilising SEAS to enhance access to specialist treatment, SDH established the Sydney Local Health District Specialist Oral Health Access Scheme (SOHAS) in 2024, including the provisions of SEAS, along with infrastructure to refer other specialist care should the need arise. It is essential to understand the experiences of patients utilising the SEAS pathway for care so as to ensure that future schemes where public-private partnerships are leveraged can be as effective and patient-centred as possible. Methods This research report has been composed following the Standards for Reporting Qualitative Research (SRQR) [ 7 ]. In accordance with the Declaration of Helsinki, ethical approval for this evaluation was provided by Royal Prince Alfred Human Research Ethics Committee of Sydney Local Health District (X22-0055 & 2022/ETH00370). Participants were limited to those patients who had received a voucher to access endodontic treatment through SEAS. A total of 187 patients were contacted by post who had received a SEAS voucher and who were therefore eligible to participate. Distribution by post was chosen due to previous research demonstrating greater engagement from a postal invitation than more contemporary electronic means of distributing an invitation to engage [ 8 ]. Participants who indicated that they would be happy to take part in an in-depth interview were interviewed using teleconferencing, with some patients preferring to attend face-to-face for an interview. Interviews were transcribed verbatim and the transcripts subjected to thematic analysis [ 9 , 10 ]. Participant recruitment, data collection and analysis were conducted concurrently in keeping with qualitative research principles [ 11 ]. As interviews were undertaken, transcripts were reviewed and coded immediately, allowing emerging insights to inform subsequent interviews and lines of inquiry. This iterative approach enabled the researchers to refine questions, explore developing themes in greater depth, and verify interpretations with participants as the study progressed. The concurrent process of data collection and analysis enhanced the responsiveness and rigour of the study, ensuring that theoretical saturation [ 12 ] and conceptual clarity were achieved through ongoing reflection and refinement. The research team engaged in this evaluation is comprised of two dental specialists working fulltime in the public sector (a specialist in Dental Public Health and a Periodontist). Neither of the researchers were involved in the provision of endodontic clinical care to any of the participants. One researcher (ACLH) predominantly undertook the data analysis, the other researcher (ON) serving to triangulate the interpretation of the data to confirm the analytical insights drawn from the examination of the participants’ comments. Results The demographics of the participants is listed in Table 1 . Table 1 – Participant Demographics Participant ID Postcode Age Gender 1 2032 87 F 2 2110 56 F 3 2222 84 M 4 2166 65 F 5 2229 74 F 6 2506 65 F 7 2033 75 M 8 2166 46 F 9 2084 77 F 10 2530 73 F 11 2230 70 M 12 2031 64 F Participants were all metropolitan-based, being distributed from across multiple referring local health districts in New South Wales. Qualitative Analysis Five themes became evident through this analysis of the participants’ comments about their experiences through the scheme: 1) access and timeliness of care; 2) interpersonal quality and trust; 3) clinical outcomes and aftercare; 4) voucher design, policy, and continuity of care; and, 5) equity, quality, and trust in tertiary dental hospitals. The themes developed from the data are presented in Table 2 and their linkages are expanded upon and explained in turn below. Table 2 – Subthemes and Themes Overarching Themes Subthemes Access and Timeliness of Care Long Waits and System Navigation Geography, Transport, and Convenience Trade-offs Interpersonal Quality and Trust Respect, Communication, and Feeling ‘Seen’ Demeaning or Transactional Encounters Hygiene and Environment as Trust Signals Clinical Outcomes and Aftercare Pain Relief and Tooth Retention Complex Cases Handled Well Residual Defects Voucher Design, Policy, and Continuity of Care Understanding and Clarity of Voucher Conditions Administrative and Billing Issues Equity, Quality, and Trust in Tertiary Dental Hospitals High Confidence in Public and Teaching Environments Public System as Safety Net and Social Justice Comparative Judgment of Private Versus Tertiary Settings Access & Timeliness of Care Many participants’ comments related to the issue of access that the scheme raised; both in relation to the positive impacts on access created by the scheme, as well as the more persistent elements that the scheme struggled to address. Participants reported experiencing challenges with navigating the public system and highlighted how some aspects of the dental hospital infrastructure stymied access. Another subtheme within this theme of access related to participants’ geographic access to care, both from the Sydney Dental Hospital and from private providers. Long Waits and System Navigation Participants referenced the lack of specialists available to provide specialist endodontics care within the public sector, a workforce challenge that led to the development of the SEAS initiative: It was a real long time. Yes, I went to Sydney Dental Hospital and I think at the time they didn’t have one of those specialist dentists appointed … so then I had to wait a little while longer. I expected to wait, but not that long. – Participant 6 Other comments reflected the challenge for patients in making contact with the hospital: We make a call in the morning for service and they put ‘press 1 and press 2’ and play music. Yesterday I tried to call the clinic … 55 minutes … they said ‘We’ll contact you’ and they never contacted me. – Participant 3 Another participant spoke of their disappointment when, having finally obtained a voucher to have their needed treatment, they struggled to identify a practitioner who was willing to accept them for treatment: I was on the list for four years before anything happened. And when I finally got the voucher, half the dentists on the list said they don’t take it anymore. I kept ringing and ringing just trying to find someone who would. – Participant 12 Administrative barriers to access combined with geographical barriers to access in participants’ narratives relating to their struggles with accessing care, both external and internal to the SEAS initiative. Geography, Transport, and Convenience Trade-offs Participants’ shared their experiences of struggling to access both options (Sydney Dental Hospital and private practices) for their care. One participant reported how they chose to access a private practice endodontics provider over the hospital as this suited their needs better: I had to travel to Camden, but that was a lot better than going to Sydney Dental Hospital, which is in the middle of the city. I’m in Dapto … This was far more convenient to me. – Participant 10 Others shared that the central location of Sydney Dental Hospital suited them well: I take the train, the T4 line and get out at Central and there’s the Dental Hospital. It’s an incredibly accessible service for me. – Participant 11 Another participant illustrated that serving a niche scheme with low numbers of participating dentists (both advanced general dentists and specialists), where the distribution of providers is not necessarily linked to the location of the eligible dental population, created challenges for access: To get to Dee Why was a real struggle because it’s not on a train line. If I could have gone to Chatswood on the train it would have been so much easier. – Participant 12 Within the context of Sydney, Chatswood is a major transport hub on the lower north shore, with Dee Why being poorly connected by public transport in comparison. While there are a great number of dentists and specialists based in Chatswood due to its status as a hub for different facilities, there were no participating dentists on the scheme based there. For those accessing services, how the service made them feel was a key component of their experience, and this theme emerged prominently within the participant group. Interpersonal Quality & Trust Within the data, three closely-aligned subthemes emerged to comprise this overarching theme focusing on indicators of quality and trust in dental care. Patients explained how different treatment experiences whilst receiving their dental care led to them feeling either respected and valued or disrespected and demeaned. Participants’ experiences crossed all sectors and treatment environments and provided important insights into the patient journey of receiving care as a public patient. Participants also shared how they evaluated services as being either trustworthy or untrustworthy, as well as how a service providing specialist care might be evaluated by a consumer for quality. Respect, Communication, and Feeling ‘Seen’ In seeking care from the private sector, some participants shared that they entered the experience with the expectation that they might be treated differently due to not paying directly for their care: I thought I wouldn’t be treated very well because I was a public patient, but I did not experience that at all. They treated me with the utmost respect. – Participant 6 Participants also spoke at length about how, despite being happy to accept a voucher for their root canal treatment to be carried out in private practice, they valued the care provided by Sydney Dental Hospital as a tertiary facility: I trust the Dental Hospital. If I had a lot of money I’d still prefer to go there. They describe what they’re doing before doing it and they are very honest. – Participant 4 At the dental hospital they always treat me like a person, not a problem. Even the students are respectful and ask before they do anything. That makes you feel safe. – Participant 12 Participants reported valuing the detachment of the public dental services from the consideration of financial motivation, with the perception for patients being that care is less likely to be driven by commercial factors compared to privately-funded treatment in community dental practices. Despite this, one participant shared an experience where she felt that her size was used by the public clinic she attended to justify why she had to be seen in private practice with a voucher: The dentist told me I was too big and that this is the public, what do you expect. She had to kneel on the chair. It was terrible and painful. – Participant 6 Demeaning or Transactional Encounters The sensitivity to being stigmatised as a public patient was a common theme that participants reported. Some participants reported feeling that they were of less value to private practitioners due to their status as public patients. Some private ones never talk to you – they look for the voucher, do it, and that’s it. – Participant 3 Another participant also shared similar challenges using the voucher: When you hand them the voucher they’re not that keen. I’ve been embarrassed trying to use it. They still don’t fit you in; they want cash or credit-card customers first. I found that a little bit degrading … At Bondi Junction the young dentist hardly spent any time with me. I left in tears because I was treated like a second-class person for having a voucher. – Participant 12 One participant shared their perception that the dentist’s clinical decision making was influenced by what they were being paid for on the voucher, with the initial reaction from their private dentist being that a tooth needed extracting, with this changing when they realised the voucher only covered root canal treatment: He first said better take all out, then he checked the voucher and said no, you must keep it. I felt pushed. – Participant 1 Hygiene and Environment as Trust Signals Participants shared their perceptions that hygiene within the facilities where they were treated, relating universally to public facilities and private clinic, was an important measure of quality and trust: They covered me like I was going to space. They covered the floor, the tables, my hair, my body with the blue thing. They are very good in hygiene. – Participant 4 This commentary also provides insight into the expectations of those accessing publicly-funded dentistry, with its socioeconomic eligibility criteria, that treatment and the facilities where this is provided, might be reasonably expected to be substandard: The facilities are amazing. It feels like a modern hospital, not a clinic for the poor. – Participant 11 Along with their experiences around how setting and surroundings impacted attitudes towards quality, patients who had received care through the scheme also commented upon the impact the care they had received had upon their oral and general health. Clinical Outcomes & Aftercare Participants spoke within this theme about the treatment experiences that they had through the scheme. Participants shared optimistic comments about symptoms having been resolved, along with the perception that the care they received was managed well and with high levels of technical skill. Despite this, some participants spoke about having had issues with the care provided following accessing root canal treatment through the scheme. Pain Relief and Tooth Retention Multiple patients spoke about positive outcomes, specifically referencing the resolution and continued absence of pain: No pain and no problems after that. – Participant 7 Until this minute I don’t have any problems; I even forgot them. – Participant 4 It did solve the pain … a huge improvement in my dental and overall health. – Participant 11 Yes, it solved the pain, and I still have that tooth a year later. – Participant 12 Alongside the positive impact of care, participants reported feeling that their care was competently handled. Complex Cases Handled Well Participants were aware of the complexity of root canal treatment and how the provision of the treatment required a high level of skill and delicacy: It wasn’t an easy thing to do — my root was crooked — but they did a really good job and it’s been trouble-free. – Participant 10 One participant reported their faith and trust in the dentist who provided their root canal treatment, with attention being paid to the perceived length of time and care taken in undertaking the procedure. It was very difficult, and he took many extra steps. He said ‘I’ll try my best’ and he did. He knows what he’s doing. – Participant 4 However, not all participants felt so positively about the care that they received. Residual Defects While the participants who agreed to participate presented as being generally happy with their care, some reported experiencing complications. Some of these were very simple and straightforward to resolve: The cap was not levelled off properly and caused discomfort. When they finally saw me again it took a minute to fix.– Participant 9 Other issues appeared to be more complex, suggesting a significant issue with the integrity of the root canal treatment provided: Now there is a hole because the filling fell out. Food goes in it and gets smelly. It’s very disgusting. – Participant 8 Delayed management of some complications may also be an indication of the lack of cohesion between the public and private sectors that this evaluation of the scheme highlights. Voucher Design, Policy, and Continuity of Care The gap in experience and practise between the public and private sectors was highlighted within this theme, with participants sharing their experiences within the scheme where misunderstandings about the workings of the public sector and the priorities of the private sector led to impacts on the patient journey. Understanding and Clarity of Voucher Conditions There was confusion experienced by both patients and treating private dentists about the scope of the scheme and the limits to what was included within the voucher: He said we can do the root canal and fix it and put the crown; the voucher will cover you for that … When I went for the next visit he said no, sorry, I can’t do the crown, because the crown is not included … I was very angry. – Participant 8 Participants reported feeling disappointed when uncertainty arose in relation to what the voucher might cover and the value of the care that it covered: They told me the voucher covers the treatment, but after the first appointment they said it only covers half. I felt tricked, like the rules changed halfway. – Participant 12 One participant shared the alarming experience of being contacted long after their treatment and being asked to pay for their endodontics care. Two years after the treatment they called me saying I hadn’t paid. I told them I gave the voucher as payment. They said maybe I still owe $ 200. I asked them to check and never heard again. – Participant 9 The administrative process associated with the vouchers appeared to be associated with some confusion, with the unaligned nexus between the public and private sector being a source of a lack of clarity: When I rang Sydney Dental Hospital they said be patient, you’re on the waitlist, but it wasn’t clear what that meant once the voucher was issued. I didn’t know who was managing what. – Participant 9 The lack of alignment between the public and private sectors is highlighted by further administrative and coordination issues experienced and reported by the participants. Administrative and Billing Issues Miscommunication and misunderstanding in relation to how funding through the scheme was allocated and worked was commonly reported by participants and appeared to not only impact them, but private providers also: He [the dentist] said any money left will go back to the hospital. I thought that was strange because it was sent to fix one tooth. I didn’t get the full treatment, but the money still went back. – Participant 8 One of the specialist providers within the scheme retired, having provided public patients with care. One participant reported that this impacted her ability to access follow-up care, and that she did not seek supportive follow-up from either her local dental clinic, or from Sydney Dental Hospital: The private clinic closed and they said they can’t fix my tooth because they already claimed the voucher. – Participant 2 While the experiences supplied by participants would suggest that, on the whole, they were happy with the prospect of seeing a private general dentist or specialist for their treatment when capacity impacted the public sector’s potential to manage them directly, there was an inherent trust placed in tertiary referral centres. Equity, Quality, and Trust in Tertiary Dental Hospitals While trust in relation to individual markers of trust in practitioners has already been explored in an earlier theme, in this final theme, participants explored their attitudes towards larger, more specialised facilities for complex dental care, and their preferences for accessing their dental treatment when funded by the public sector. High Confidence in Public and Teaching Environments Some participants shared that the close association with teaching and higher education was a strong indicator of quality and accountability for them when they received their care at a public facility. One patient especially noted the impact that having senior academics involved in their care made on them, and their belief that this heightened the quality and trustworthiness of their care: As a teaching hospital … having the Professor come in and check the work is incredibly reassuring … I feel privileged to have such high-quality dental care. – Participant 11 One participant felt that the dental hospital was a better environment for care due to having communication challenges in the private sector, along with the perception that private dentistry is expensive: I’d recommend the Dental Hospital to anyone. The private ones charge the earth and don’t explain. – Participant 6 Patients accessing public dental care were aware that the system is means-tested and oriented to provide care to the most vulnerable patients in the community, a sentiment explored in more detail within the next subtheme. Public System as Safety Net and Social Justice Despite the service’s orientation as a safety net service, patients acknowledged both the value this had to them personally, and also the level of care that the public system was able to provide: I’d be in a terrible state if I hadn’t had access … It’s there for a reason … I think it’s an exceptionally high-quality public system. – Participant 11 If you can’t afford private, at least you can still get help. That means a lot when you’re on a pension. – Participant 12 Some participants had experienced receiving outsourced care through the SEAS initiative, and also having received general dental care through the larger, state-wide Oral Health Fee For Service Scheme (OHFFSS). One participant shared that she had a poor experience with a private practitioner when accessing general care and a good experience accessing a private specialist: We’re on a pension. I wouldn’t go back to the previous dentist (accessed on a previous general care voucher) but would definitely go back to the Specialist Endodontist. I’m very grateful. – Participant 10 Such experiences highlight again that consistency, both between private practitioners and between private practitioners and the public sector, is an aspect of outsourcing care from public environments into the private sector that needs to be better addressed. Comparative Judgment of Private Versus Tertiary Settings When patients were asked about their experiences and which environment they preferred, many patients who had received a voucher to have care in the private sector stated that they were happy with the care that they received, but that they would have preferred to visit the dental hospital. One participant stated that they felt the treatment quality between public and private providers was comparable, but that the professionalism of providers at the hospital was of particular note: If I could have had the treatment at the dental hospital, I’d have chosen it … I don’t think there’s any qualitative difference in the treatment, but the reassurance and professionalism there are exceptional. – Participant 11 Closely associated was the perception of a greater level of care and attention to detail at the hospital: I think it would be the same, but with the hospital you know they check and double-check everything. – Participant 9 Another patient noted the trade-off between speed of treatment and patient journey taking longer at the hospital, but the trust and reliability of the hospital being greater. Private is faster if you can find one who’ll take the voucher. But the hospital—you can trust what they tell you. – Participant 12 This demonstrates the importance of understanding patient values and priorities when communicating about such schemes and the opportunity to have care outsourced into the private sector. Discussion The NSW public system is vulnerable to loss of dental specialist capacity due to perceived disparities between the salaries provided for by the State Award and specialist earning potential in private practice. The eligible population of NSW is potentially left with little specialist coverage if existing coverage from metropolitan services is lost, and those who are based in region and remote areas suffer even greater disadvantage from lack of access [ 13 ]. This research demonstrates that patients were positively impacted by the establishment of a mechanism to refer specialist oral health treatment into existing private infrastructure within the community. This both increased the number of practitioners available to provide advanced specialist care, as well as allowed patients to access care nearer to where they live. The SEAS initiative represents an appropriate, patient-centred approach to addressing maldistribution of dental specialists and how engagement with the private sector can mitigate the challenge of attracting advanced dental skills capacity into the NSW public sector. While the SEAS pathway enabled access for some participants who found contracted providers closer to home, others described substantial travel burdens, particularly where contracted sites lacked rail connectivity or were outside major transport hubs. Participants also contrasted the centrality and rail access of SDH with bus-dependent locations in the private network. Participant experiences reveal that SEAS improved access in principle but did not guarantee local convenience, with geographic benefit being variable rather than universal. This suggests that there was an inadequacy within the scheme of having enough providers with sufficient geographic distribution to fully mitigate the issue of geographic access. The uneven spatial distribution of contracted providers underscores the need for geospatial modelling in future specialist access schemes, a common theme in addressing inequitable dental access as demonstrated by previous general assessment of dental workforce distribution within Australia [ 14 ]. While this could be mitigated in future iterations of the scheme, or those like it, it demonstrates the inherent maldistribution of specialist dental capacity, which is accentuated by only small numbers of potential providers being willing to participate. Those accessing dental care in the NSW public system are the most disadvantaged and vulnerable in our community. Participants detailed their physical challenges, both due to disability and geography, in accessing advanced endodontic care. The narratives provided by participants in relation to the impact accessing treatment had on their wellbeing and quality of life demonstrate the importance of root canal treatment being available to patients in the public system. Recent discussion has imagined how additional dental services might be covered by Medicare [ 15 , 16 ]. Participants in this study were mixed in their views as to whether more complex dental treatment such as root canal treatment should be covered under a prospective scheme. This research provides additional insight into the meaningfulness of including root canal treatment within the provisions of a future expansion of oral health service provision as an essential part of holistic oral healthcare. This evaluation of the scheme also demonstrates the benefits of maintaining specialist capacity within the public sector, especially within tertiary care environments in collaboration with education and training programs. Patients detailed their perceptions of how multi-specialist teams and academic involvement in their care were significant marks of quality. While SEAS was successful in increasing the access of patients in the NSW public sector to specialist endodontists, as highlighted earlier it is of note that only 5 specialist practitioners of the 59 registered across NSW and ACT at the time of the scheme’s establishment chose to participate. There may be several factors as to why limited specialist participation was observed, deeper understanding of this would be important for the future success of specialist access schemes in the NSW public oral health services. Participants’ accounts revealed that, for some, voucher use was accompanied by stigma or transactional encounters, while others experienced respectful, high-quality interactions across both sectors. Given the program’s focus on socioeconomically eligible populations, patient dignity must be treated as a quality domain, not a by-product. Previous research has shown stigma towards public patients from private practitioners and dental students, and whilst this is by no means representative across the private sector demographic, this may be a factor in low participation [ 17 , 18 ]. Similarly, prior investigation demonstrates that stigma relating to oral healthcare, in particular the issues of affordability, is a wider phenomenon expanding beyond the boundaries of this niche scheme [ 19 – 21 ]. How this is addressed within the context of socio-economically disadvantaged patients and their experiences with accessing care in the private sector warrants further exploration in regards to future iterations of public-private oral healthcare partnerships. While some participants detailed experiencing stigma when accessing care through private providers as public patients, the majority did not, with the main barrier to harmonious experience through the scheme being a lack of alignment between the public and private sectors. Participants frequently reported uncertainty about voucher inclusions (e.g., whether a crown was covered), post-hoc billing queries, and unclear points of contact once a voucher was issued. These pain points indicate that administrative opacity, rather than clinical care per se, was a principal source of dissatisfaction. Several participants described uncertainty about who was responsible for follow-up, defect remediation, or retreatment, particularly when a contracted clinic closed or a clinician left. Future iterations of this scheme, as well as other fee-for-service schemes referring public patients into private care should achieve improved alignment through philosophical calibration (to avoid stigmatising behaviours), ensuring the scope of the scheme is well understood, and further stakeholder engagement with private providers to improve the administration of the scheme. Recommended Enhancements Based on Evaluation Results While this qualitative evaluation has demonstrated acceptability of the scheme to patients, the participants’ experiences also allow scope for improvements that could be incorporated within future iterations of this scheme and others like it to enhance the patient journey. 1) Enhance Administrative Integration and Voucher Transparency Participants reported confusion in relation to the voucher inclusion and were impacted by participating clinicians being unaware of how to use the vouchers. While patients were provided with explanatory guidance where the voucher was issued, future iterations of the scheme would benefit from providing detailed information and ‘frequently asked questions’ to patients to help navigate the scheme. The SEAS program was articulated professionally through a policy document that was issued to participating practitioners and set out business rules for the scheme. This framework could be adapted into a patient-focused document, written in an accessible manner, to allow patients to better understand the relevant rules and inclusions of the scheme. 2) Enhancing Administrative Integration Each private dental provider is an isolated unit, being administratively and clinically separate from the rest of the healthcare system. This means coordinating a public-private partnership with private providers can be fraught with issues around organising care (e.g. provision of initial treatment direction and handover upon treatment completion). Understanding whether integrating private providers within the public sector’s administrative infrastructure in a closer manner is not a task to be undertaken lightly, however, many of the participants’ experiences were marred by a lack of coordination and ability for private providers and the public sector commissioning care to effectively collaborate. Solutions within this theme could be to integrate access to public sector clinical record systems, or to establish a shared electronic workflow system for those commissioning services to better communicate with private sector dental providers. 3) Enhancing Cultural Integration Some participants reported feeling embarrassed or stigmatised when presenting vouchers to private practitioners. While this was by no means a universal experience, the scheme did not actively curate the response of private practitioners to the myriad of social and cultural relevancies that apply when providing care to socioeconomically disadvantaged patients. Due to the nature of private dentistry in Australia being self-funded (either through insurance or directly through out-of-pocket costs), private practitioners may not have competencies in managing these demographics of patients. Future iterations of the scheme could be enhanced through development of a training module for private providers, to help support them in developing ‘social competency’; where care can be provided to disadvantaged socio-economic and cultural groups in a safe manner. Experiences of embarrassment and transactional interactions highlight that patient dignity must be considered a measurable quality outcome. Incorporating PREMs focused on respect, communication, and inclusion would operationalise the ‘partnering with consumers’ pillar of the Future Health Framework [ 6 ]. The experiences of public patients referred to private providers may also form part of future iterations of existing experience and outcome measurement tools used to evaluate public oral health services [ 22 ]. Limitations As with all qualitative research, the findings of this study are limited to the space, time and context in which the data were collected, analysed, as well as the interpretation of the research team. Different insights, experiences and themes might have emerged with a different set of participants’ providing their reflections [ 23 ]. Despite this, the insights collected in this research have meaning and provide a valuable contribution to the literature considering different approaches to how publicly provided dental care might be organised. The sample was limited to participants willing to be interviewed, likely biasing toward those with strong experiences (positive or negative). However, the convergence observed across multiple themes strengthens the credibility of this analysis. Conclusions SEAS allowed enhanced access to complex endodontics care for patients who would have otherwise not had this care. Future public-private partnerships for specialist care will need to build on this success and develop additional scheme infrastructure to improve patient experience and outcomes. This qualitative evaluation of the SEAS initiative demonstrates how challenges in accessing specialist and specialised dental care within the public sector can be effectively ameliorated through engaging practitioners based within the private sector. Central to the benefits of this approach are high levels of patient acceptability and enhancements to the geographic accessibility of endodontic care. This scheme had the benefit of engaging smaller numbers of participating practitioners than other public-private initiatives. Scaled efforts to further access may reveal different challenges and tensions in enhancing access. This research also provides insight into the importance of root canal treatment for those who receive it, with the impact to quality of life being highlighted by the participants’ narratives. Future initiatives in the NSW public oral health sector that utilise this approach should further improve the administrative infrastructure used to organise and implement the provision of care to better improve patient experience. This research demonstrated the impact of receiving advanced endodontics care on the patients who shared their experiences. This highlights the importance of the public sector oral health services retaining a sufficient scope of complexity to be able to offer such clinical outcomes. Abbreviations and acronyms SEAS Sydney Local Health District Endodontic Access Scheme DVA Department of Veterans’ Affairs SDH Sydney Dental Hospital OHFFSS Oral Health Fee For Service Scheme Declarations Ethics approval and consent to participate In accordance with the Declaration of Helsinki, ethical approval for this evaluation was provided by Royal Prince Alfred Human Research Ethics Committee of Sydney Local Health District (X22-0055 & 2022/ETH00370). All participants provided informed consent to participate in this research. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests Funding The publication costs of this research were funded by Sydney Dental Hospital, SLHD Author Contribution AH was involved in conceptualisation of this research, ethical approval, data collection, data analysis and drafting and revision of the manuscript. ON was involved in data analysis and drafting and revision of the manuscript. Both AH and ON approved the final version of the manuscript. Acknowledgement The authors wish to acknowledge the contribution of Shilpi Ajwani, Kim Hartley and Trupta Desai in the early stages of this research with conceptualisation and crafting of research materials. The authors also acknowledge the contribution of Daniella Beeto and Ploynaplus Srishataroon in data collection. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Eligibility of Persons for Public Oral Health Care. in NSW [ https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_027.pdf] Specialist Registration. [ https://www.dentalboard.gov.au/Registration/Specialist-Registration.aspx] Oral Health Fee for Service Scheme. [ https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2016_018.pdf] American Association of Endodontists. AAE Endodontic Case Difficulty Assessment Form and Guidelines. In.; 2022. European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J. 2006;39(12):921–30. New South Wales Ministry of Health. Future health: guiding the next decade of care in NSW 2022–2032 In. St Leonards, NSW; 2022. O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51. Dillman DA. Internet, phone, mail, and mixed-mode surveys: the tailored design method, Fourth edition. edn. Hoboken, New Jersey: Wiley; 2014. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Braun V, Clarke V. Toward good practice in thematic analysis: Avoiding common problems and be(com)ing a knowing researcher. Int J Transgender Health. 2023;24(1):1–6. Byrne D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Qual Quant. 2022;56(3):1391–412. Braun V, Clarke V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qualitative Res Sport Exerc Health. 2021;13(2):201–16. Willie-Stephens J, Kruger E, Tennant M. Public and private dental services in NSW: a geographic information system analysis of access to care for 7 million Australians. N S W Public Health Bull. 2014;24(4):164–70. Jean G, Kruger E, Tennant M. The distribution of dentists in Australia Socio-economic profile as an indicator of access to services. Community Dent Health. 2020;37(1):5–11. Hopcraft MS, Holden A. Australian dental practitioner attitudes to expanding Medicare to include more dental services. Aust Dent J. 2025;70(3):171–80. Holden ACL, Hopcraft MS. Control, access and professionalism: a qualitative evaluation of Australian dental practitioners attitudes to expanding medicare to include more dental services. BMC Oral Health. 2025;25(1):1283. Holden ACL, Adam L, Thomson M. Private practice dentists' views of oral health injustice. Community Dent Health. 2021;38(4):268–74. Holden ACL, Leadbeatter D. Conceptualisations of the social determinants of health among first-year dental students. BMC Med Educ. 2021;21(1):164. Doughty J, Macdonald ME, Muirhead V, Freeman R. Oral health-related stigma: Describing and defining a ubiquitous phenomenon. Commun Dent Oral Epidemiol. 2023;51(6):1078–83. Folker L, Jespersen AP, Øzhayat EB. Tooth shame - An ethnographic study of the choreographies of tooth shame in Danish elderly care. Soc Sci Med. 2025;365:117500. Zain Ul Abideen M, Ali Bushara NA, Nadeem Baig M, Dilshad Siddiqui Y, Ejaz I, Tareen J, Siddiqui AA. Shining a Spotlight on Stigma: Exploring Its Impact on Oral Health-Seeking Behaviours Through the Lenses of Patients and Caregivers. Cureus. 2024;16(6):e63025. Chen R, Ajwani S, Christian B, Phelan C, Srinivas R, Kenny J, O’Connor M, Clarke K, Sohn W, Yaacoub A. The development of a new oral health patient reported outcome measure: the New South Wales public dental services approach. J Patient-Reported Outcomes. 2024;8(1):98. Tonkiss F. Analysing discourse. In: Researching Society and Culture. edn. Edited by Seale C. London: SAGE; 1998: 245–260. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Apr, 2026 Reviews received at journal 25 Feb, 2026 Reviews received at journal 22 Feb, 2026 Reviewers agreed at journal 18 Feb, 2026 Reviews received at journal 17 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviewers agreed at journal 12 Feb, 2026 Reviewers invited by journal 11 Feb, 2026 Editor invited by journal 21 Jan, 2026 Editor assigned by journal 22 Nov, 2025 Submission checks completed at journal 22 Nov, 2025 First submitted to journal 19 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8154782","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":591753391,"identity":"1945d30f-9cac-4fd8-b11f-4ef2641a6603","order_by":0,"name":"Alexander C L Holden","email":"data:image/png;base64,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","orcid":"","institution":"The University of Sydney School of Dentistry","correspondingAuthor":true,"prefix":"","firstName":"Alexander","middleName":"C L","lastName":"Holden","suffix":""},{"id":591753393,"identity":"06c85343-0309-4d24-8fa8-ba7898750522","order_by":1,"name":"Olivia Nova","email":"","orcid":"","institution":"The University of Sydney School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Olivia","middleName":"","lastName":"Nova","suffix":""}],"badges":[],"createdAt":"2025-11-19 11:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8154782/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8154782/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106723444,"identity":"a1a4e313-2fa7-4f9e-a3dc-ad4eef779547","added_by":"auto","created_at":"2026-04-12 17:44:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":968371,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8154782/v1/85d963f3-5ae5-4bed-87a8-3c4a1371bafa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Qualitative Evaluation of Patient Experiences of Receiving Endodontic Treatment Through the Sydney Local Health District Endodontic Access Scheme (SEAS)","fulltext":[{"header":"Background","content":"\u003cp\u003eThe dental health of the eligible population of the State of NSW is provided for by the oral health services operated by NSW Health. Unlike other public health services which operate on an enviable provision of universal access, the NSW public oral health services operate on a basis of socioeconomic eligibility, which includes children under 18 with a Medicare card, and adults with certain Australian government concession cards [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The state provides a \u0026lsquo;safety net\u0026rsquo; service for those who cannot afford to access care in the private sector where most of dental care is provided. For those who are eligible, the service is comprehensive, offering access to both general and specialist dental care based on prioritisation and assessed clinical need. For those who meet specific criteria for accessing different specialist services, the state offers access to all 13 specialist dental disciplines [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe specialist field of endodontics focuses on the management of the dental pulp, dental pain and the provision of root canal treatment. Sydney Dental Hospital (SDH) is one of two main tertiary dental referral services in NSW, but the only centre that accepts statewide referrals for endodontic care. In early 2021, SDH lost the only fulltime specialist endodontist working in the NSW public sector to retirement, with visiting dental officers (part time contracted specialists) then being completely relied upon for specialist workforce to provide endodontics. Despite multiple rounds of advertisement, SDH could not replace this lost specialist capacity. Shortly after, with 577 patients on SDH\u0026rsquo;s waiting list - which was further exacerbated by the impacts of the COVID 19 pandemic on public oral health activity - SDH had to cease accepting referrals for specialist endodontics. Elsewhere within NSW Health public oral health services, where clinical capacity is lacking, general dental services can refer to the private sector. This is facilitated through the Oral Health Fee For Service Scheme (OHFFSS) which issues paper vouchers to patients which allow them to seek specific treatments to a certain value from participating private practitioners [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile the OHFFSS supports access to emergency, general dental and denture treatment, access schemes have not had widespread application for specialist dental care. Due to having a high number of patients waiting for care and no other option within the NSW public oral health service, a decision was made to establish a specialist access scheme for endodontics the Sydney Local Health District Endodontic Access Scheme (SEAS). While the OHFFSS does accommodate the provision of root canal treatment, the financial amount provided would not satisfy the expectations of specialist or most general dentists with a special interest in Endodontics. In consultation with the state branch of the Australian Society of Endodontology, agreement was reached that fees would be set at the same quantum as the Department of Veteran\u0026rsquo;s Affairs dental fee schedule. Subsequent recruitment of private practitioners was conducted through an expression of interest promoted through the NSW branches of the Australian Dental Association and the Australian Society of Endodontology to identify suitable specialists and general dentists with advanced skills in endodontics.\u003c/p\u003e \u003cp\u003ePrior to cases being referred to the private sector through SEAS, they were categorised for complexity using local criteria based on international standards and guidance [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], developed with input from the University of Sydney School of Dentistry. Practitioners who expressed interest in participating were asked to self-assess their capacity to manage moderately complex and complex endodontic cases based on the published criteria. A total of 22 general dentists with a special interest in endodontics and self-assessed advanced experience and 5 specialist endodontists were recruited from across NSW and ACT to accept referrals through the scheme.\u003c/p\u003e \u003cp\u003eFollowing a process of being assessed through teledentistry, a total of 187 public patients received a voucher in 2022 to allow access to advanced care in the NSW private sector. This strategy allowed SDH to effectively manage demand for advanced endodontics care, alongside other activities to enhance specialist capacity such as establishing the Doctor of Clinical Dentistry training program in Endodontics in collaboration with the University of Sydney School of Dentistry. The SEAS initiative directly operationalises NSW Health\u0026rsquo;s Future Health: Strategic Framework 2022\u0026ndash;2032, particularly through the goals of delivering safe care across all settings, partnering with consumers and ensuring equitable access [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. By engaging extant private-sector infrastructure to address specialist workforce shortages, SEAS exemplifies the framework\u0026rsquo;s call for integrated, patient-centred care.\u003c/p\u003e \u003cp\u003e Following the experiences of utilising SEAS to enhance access to specialist treatment, SDH established the Sydney Local Health District Specialist Oral Health Access Scheme (SOHAS) in 2024, including the provisions of SEAS, along with infrastructure to refer other specialist care should the need arise. It is essential to understand the experiences of patients utilising the SEAS pathway for care so as to ensure that future schemes where public-private partnerships are leveraged can be as effective and patient-centred as possible.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis research report has been composed following the Standards for Reporting Qualitative Research (SRQR) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In accordance with the Declaration of Helsinki, ethical approval for this evaluation was provided by Royal Prince Alfred Human Research Ethics Committee of Sydney Local Health District (X22-0055 \u0026amp; 2022/ETH00370). Participants were limited to those patients who had received a voucher to access endodontic treatment through SEAS. A total of 187 patients were contacted by post who had received a SEAS voucher and who were therefore eligible to participate. Distribution by post was chosen due to previous research demonstrating greater engagement from a postal invitation than more contemporary electronic means of distributing an invitation to engage [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Participants who indicated that they would be happy to take part in an in-depth interview were interviewed using teleconferencing, with some patients preferring to attend face-to-face for an interview. Interviews were transcribed verbatim and the transcripts subjected to thematic analysis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Participant recruitment, data collection and analysis were conducted concurrently in keeping with qualitative research principles [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. As interviews were undertaken, transcripts were reviewed and coded immediately, allowing emerging insights to inform subsequent interviews and lines of inquiry. This iterative approach enabled the researchers to refine questions, explore developing themes in greater depth, and verify interpretations with participants as the study progressed. The concurrent process of data collection and analysis enhanced the responsiveness and rigour of the study, ensuring that theoretical saturation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and conceptual clarity were achieved through ongoing reflection and refinement.\u003c/p\u003e \u003cp\u003eThe research team engaged in this evaluation is comprised of two dental specialists working fulltime in the public sector (a specialist in Dental Public Health and a Periodontist). Neither of the researchers were involved in the provision of endodontic clinical care to any of the participants. One researcher (ACLH) predominantly undertook the data analysis, the other researcher (ON) serving to triangulate the interpretation of the data to confirm the analytical insights drawn from the examination of the participants\u0026rsquo; comments.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographics of the participants is listed in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Participant Demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostcode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2506\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2530\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eParticipants were all metropolitan-based, being distributed from across multiple referring local health districts in New South Wales.\u003c/p\u003e\n\u003ch3\u003eQualitative Analysis\u003c/h3\u003e\n\u003cp\u003eFive themes became evident through this analysis of the participants\u0026rsquo; comments about their experiences through the scheme: 1) access and timeliness of care; 2) interpersonal quality and trust; 3) clinical outcomes and aftercare; 4) voucher design, policy, and continuity of care; and, 5) equity, quality, and trust in tertiary dental hospitals. The themes developed from the data are presented in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and their linkages are expanded upon and explained in turn below.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Subthemes and Themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverarching Themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAccess and Timeliness of Care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLong Waits and System Navigation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeography, Transport, and Convenience Trade-offs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eInterpersonal Quality and Trust\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRespect, Communication, and Feeling \u0026lsquo;Seen\u0026rsquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDemeaning or Transactional Encounters\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHygiene and Environment as Trust Signals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eClinical Outcomes and Aftercare\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain Relief and Tooth Retention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplex Cases Handled Well\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResidual Defects\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eVoucher Design, Policy, and Continuity of Care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstanding and Clarity of Voucher Conditions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdministrative and Billing Issues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEquity, Quality, and Trust in Tertiary Dental Hospitals\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh Confidence in Public and Teaching Environments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic System as Safety Net and Social Justice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComparative Judgment of Private Versus Tertiary Settings\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eAccess \u0026 Timeliness of Care\u003c/h3\u003e\n\u003cp\u003eMany participants\u0026rsquo; comments related to the issue of access that the scheme raised; both in relation to the positive impacts on access created by the scheme, as well as the more persistent elements that the scheme struggled to address.\u003c/p\u003e \u003cp\u003eParticipants reported experiencing challenges with navigating the public system and highlighted how some aspects of the dental hospital infrastructure stymied access. Another subtheme within this theme of access related to participants\u0026rsquo; geographic access to care, both from the Sydney Dental Hospital and from private providers.\u003c/p\u003e\n\u003ch3\u003eLong Waits and System Navigation\u003c/h3\u003e\n\u003cp\u003eParticipants referenced the lack of specialists available to provide specialist endodontics care within the public sector, a workforce challenge that led to the development of the SEAS initiative:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt was a real long time. Yes, I went to Sydney Dental Hospital and I think at the time they didn\u0026rsquo;t have one of those specialist dentists appointed \u0026hellip; so then I had to wait a little while longer. I expected to wait, but not that long. \u0026ndash; Participant 6\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOther comments reflected the challenge for patients in making contact with the hospital:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe make a call in the morning for service and they put \u0026lsquo;press 1 and press 2\u0026rsquo; and play music. Yesterday I tried to call the clinic \u0026hellip; 55 minutes \u0026hellip; they said \u0026lsquo;We\u0026rsquo;ll contact you\u0026rsquo; and they never contacted me. \u0026ndash; Participant 3\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant spoke of their disappointment when, having finally obtained a voucher to have their needed treatment, they struggled to identify a practitioner who was willing to accept them for treatment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI was on the list for four years before anything happened. And when I finally got the voucher, half the dentists on the list said they don\u0026rsquo;t take it anymore. I kept ringing and ringing just trying to find someone who would. \u0026ndash; Participant 12\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdministrative barriers to access combined with geographical barriers to access in participants\u0026rsquo; narratives relating to their struggles with accessing care, both external and internal to the SEAS initiative.\u003c/p\u003e\n\u003ch3\u003eGeography, Transport, and Convenience Trade-offs\u003c/h3\u003e\n\u003cp\u003eParticipants\u0026rsquo; shared their experiences of struggling to access both options (Sydney Dental Hospital and private practices) for their care. One participant reported how they chose to access a private practice endodontics provider over the hospital as this suited their needs better:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI had to travel to Camden, but that was a lot better than going to Sydney Dental Hospital, which is in the middle of the city. I\u0026rsquo;m in Dapto \u0026hellip; This was far more convenient to me. \u0026ndash; Participant 10\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOthers shared that the central location of Sydney Dental Hospital suited them well:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI take the train, the T4 line and get out at Central and there\u0026rsquo;s the Dental Hospital. It\u0026rsquo;s an incredibly accessible service for me. \u0026ndash; Participant 11\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant illustrated that serving a niche scheme with low numbers of participating dentists (both advanced general dentists and specialists), where the distribution of providers is not necessarily linked to the location of the eligible dental population, created challenges for access:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTo get to Dee Why was a real struggle because it\u0026rsquo;s not on a train line. If I could have gone to Chatswood on the train it would have been so much easier. \u0026ndash; Participant 12\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWithin the context of Sydney, Chatswood is a major transport hub on the lower north shore, with Dee Why being poorly connected by public transport in comparison. While there are a great number of dentists and specialists based in Chatswood due to its status as a hub for different facilities, there were no participating dentists on the scheme based there.\u003c/p\u003e \u003cp\u003e For those accessing services, how the service made them feel was a key component of their experience, and this theme emerged prominently within the participant group.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInterpersonal Quality \u0026amp; Trust\u003c/h2\u003e \u003cp\u003eWithin the data, three closely-aligned subthemes emerged to comprise this overarching theme focusing on indicators of quality and trust in dental care. Patients explained how different treatment experiences whilst receiving their dental care led to them feeling either respected and valued or disrespected and demeaned. Participants\u0026rsquo; experiences crossed all sectors and treatment environments and provided important insights into the patient journey of receiving care as a public patient. Participants also shared how they evaluated services as being either trustworthy or untrustworthy, as well as how a service providing specialist care might be evaluated by a consumer for quality.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRespect, Communication, and Feeling ‘Seen’\u003c/h3\u003e\n\u003cp\u003eIn seeking care from the private sector, some participants shared that they entered the experience with the expectation that they might be treated differently due to not paying directly for their care:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI thought I wouldn\u0026rsquo;t be treated very well because I was a public patient, but I did not experience that at all. They treated me with the utmost respect. \u0026ndash; Participant 6\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants also spoke at length about how, despite being happy to accept a voucher for their root canal treatment to be carried out in private practice, they valued the care provided by Sydney Dental Hospital as a tertiary facility:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI trust the Dental Hospital. If I had a lot of money I\u0026rsquo;d still prefer to go there. They describe what they\u0026rsquo;re doing before doing it and they are very honest. \u0026ndash; Participant 4\u003c/p\u003e\u003cp\u003eAt the dental hospital they always treat me like a person, not a problem. Even the students are respectful and ask before they do anything. That makes you feel safe. \u0026ndash; Participant 12\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants reported valuing the detachment of the public dental services from the consideration of financial motivation, with the perception for patients being that care is less likely to be driven by commercial factors compared to privately-funded treatment in community dental practices. Despite this, one participant shared an experience where she felt that her size was used by the public clinic she attended to justify why she had to be seen in private practice with a voucher:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe dentist told me I was too big and that this is the public, what do you expect. She had to kneel on the chair. It was terrible and painful. \u0026ndash; Participant 6\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eDemeaning or Transactional Encounters\u003c/h3\u003e\n\u003cp\u003e The sensitivity to being stigmatised as a public patient was a common theme that participants reported. Some participants reported feeling that they were of less value to private practitioners due to their status as public patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSome private ones never talk to you \u0026ndash; they look for the voucher, do it, and that\u0026rsquo;s it. \u0026ndash; Participant 3\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant also shared similar challenges using the voucher:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen you hand them the voucher they\u0026rsquo;re not that keen. I\u0026rsquo;ve been embarrassed trying to use it. They still don\u0026rsquo;t fit you in; they want cash or credit-card customers first. I found that a little bit degrading \u0026hellip; At Bondi Junction the young dentist hardly spent any time with me. I left in tears because I was treated like a second-class person for having a voucher. \u0026ndash; Participant 12\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne participant shared their perception that the dentist\u0026rsquo;s clinical decision making was influenced by what they were being paid for on the voucher, with the initial reaction from their private dentist being that a tooth needed extracting, with this changing when they realised the voucher only covered root canal treatment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHe first said better take all out, then he checked the voucher and said no, you must keep it. I felt pushed. \u0026ndash; Participant 1\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eHygiene and Environment as Trust Signals\u003c/h2\u003e \u003cp\u003eParticipants shared their perceptions that hygiene within the facilities where they were treated, relating universally to public facilities and private clinic, was an important measure of quality and trust:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey covered me like I was going to space. They covered the floor, the tables, my hair, my body with the blue thing. They are very good in hygiene. \u0026ndash; Participant 4\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis commentary also provides insight into the expectations of those accessing publicly-funded dentistry, with its socioeconomic eligibility criteria, that treatment and the facilities where this is provided, might be reasonably expected to be substandard:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe facilities are amazing. It feels like a modern hospital, not a clinic for the poor. \u0026ndash; Participant 11\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlong with their experiences around how setting and surroundings impacted attitudes towards quality, patients who had received care through the scheme also commented upon the impact the care they had received had upon their oral and general health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eClinical Outcomes \u0026amp; Aftercare\u003c/h2\u003e \u003cp\u003eParticipants spoke within this theme about the treatment experiences that they had through the scheme. Participants shared optimistic comments about symptoms having been resolved, along with the perception that the care they received was managed well and with high levels of technical skill. Despite this, some participants spoke about having had issues with the care provided following accessing root canal treatment through the scheme.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePain Relief and Tooth Retention\u003c/h2\u003e \u003cp\u003eMultiple patients spoke about positive outcomes, specifically referencing the resolution and continued absence of pain:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eNo pain and no problems after that. \u0026ndash; Participant 7\u003c/p\u003e\u003cp\u003eUntil this minute I don\u0026rsquo;t have any problems; I even forgot them. \u0026ndash; Participant 4\u003c/p\u003e\u003cp\u003eIt did solve the pain \u0026hellip; a huge improvement in my dental and overall health. \u0026ndash; Participant 11\u003c/p\u003e\u003cp\u003eYes, it solved the pain, and I still have that tooth a year later. \u0026ndash; Participant 12\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlongside the positive impact of care, participants reported feeling that their care was competently handled.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eComplex Cases Handled Well\u003c/h2\u003e \u003cp\u003eParticipants were aware of the complexity of root canal treatment and how the provision of the treatment required a high level of skill and delicacy:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt wasn\u0026rsquo;t an easy thing to do \u0026mdash; my root was crooked \u0026mdash; but they did a really good job and it\u0026rsquo;s been trouble-free. \u0026ndash; Participant 10\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne participant reported their faith and trust in the dentist who provided their root canal treatment, with attention being paid to the perceived length of time and care taken in undertaking the procedure.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt was very difficult, and he took many extra steps. He said \u0026lsquo;I\u0026rsquo;ll try my best\u0026rsquo; and he did. He knows what he\u0026rsquo;s doing. \u0026ndash; Participant 4\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, not all participants felt so positively about the care that they received.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eResidual Defects\u003c/h2\u003e \u003cp\u003eWhile the participants who agreed to participate presented as being generally happy with their care, some reported experiencing complications. Some of these were very simple and straightforward to resolve:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe cap was not levelled off properly and caused discomfort. When they finally saw me again it took a minute to fix.\u0026ndash; Participant 9\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOther issues appeared to be more complex, suggesting a significant issue with the integrity of the root canal treatment provided:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eNow there is a hole because the filling fell out. Food goes in it and gets smelly. It\u0026rsquo;s very disgusting. \u0026ndash; Participant 8\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDelayed management of some complications may also be an indication of the lack of cohesion between the public and private sectors that this evaluation of the scheme highlights.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eVoucher Design, Policy, and Continuity of Care\u003c/h2\u003e \u003cp\u003eThe gap in experience and practise between the public and private sectors was highlighted within this theme, with participants sharing their experiences within the scheme where misunderstandings about the workings of the public sector and the priorities of the private sector led to impacts on the patient journey.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eUnderstanding and Clarity of Voucher Conditions\u003c/h2\u003e \u003cp\u003eThere was confusion experienced by both patients and treating private dentists about the scope of the scheme and the limits to what was included within the voucher:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHe said we can do the root canal and fix it and put the crown; the voucher will cover you for that \u0026hellip; When I went for the next visit he said no, sorry, I can\u0026rsquo;t do the crown, because the crown is not included \u0026hellip; I was very angry. \u0026ndash; Participant 8\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants reported feeling disappointed when uncertainty arose in relation to what the voucher might cover and the value of the care that it covered:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey told me the voucher covers the treatment, but after the first appointment they said it only covers half. I felt tricked, like the rules changed halfway. \u0026ndash; Participant 12\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne participant shared the alarming experience of being contacted long after their treatment and being asked to pay for their endodontics care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTwo years after the treatment they called me saying I hadn\u0026rsquo;t paid. I told them I gave the voucher as payment. They said maybe I still owe \u003cspan\u003e$\u003c/span\u003e200. I asked them to check and never heard again. \u0026ndash; Participant 9\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe administrative process associated with the vouchers appeared to be associated with some confusion, with the unaligned nexus between the public and private sector being a source of a lack of clarity:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen I rang Sydney Dental Hospital they said be patient, you\u0026rsquo;re on the waitlist, but it wasn\u0026rsquo;t clear what that meant once the voucher was issued. I didn\u0026rsquo;t know who was managing what. \u0026ndash; Participant 9\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe lack of alignment between the public and private sectors is highlighted by further administrative and coordination issues experienced and reported by the participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eAdministrative and Billing Issues\u003c/h2\u003e \u003cp\u003eMiscommunication and misunderstanding in relation to how funding through the scheme was allocated and worked was commonly reported by participants and appeared to not only impact them, but private providers also:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHe [the dentist] said any money left will go back to the hospital. I thought that was strange because it was sent to fix one tooth. I didn\u0026rsquo;t get the full treatment, but the money still went back. \u0026ndash; Participant 8\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne of the specialist providers within the scheme retired, having provided public patients with care. One participant reported that this impacted her ability to access follow-up care, and that she did not seek supportive follow-up from either her local dental clinic, or from Sydney Dental Hospital:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe private clinic closed and they said they can\u0026rsquo;t fix my tooth because they already claimed the voucher. \u0026ndash; Participant 2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile the experiences supplied by participants would suggest that, on the whole, they were happy with the prospect of seeing a private general dentist or specialist for their treatment when capacity impacted the public sector\u0026rsquo;s potential to manage them directly, there was an inherent trust placed in tertiary referral centres.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eEquity, Quality, and Trust in Tertiary Dental Hospitals\u003c/h2\u003e \u003cp\u003eWhile trust in relation to individual markers of trust in practitioners has already been explored in an earlier theme, in this final theme, participants explored their attitudes towards larger, more specialised facilities for complex dental care, and their preferences for accessing their dental treatment when funded by the public sector.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eHigh Confidence in Public and Teaching Environments\u003c/h2\u003e \u003cp\u003e Some participants shared that the close association with teaching and higher education was a strong indicator of quality and accountability for them when they received their care at a public facility. One patient especially noted the impact that having senior academics involved in their care made on them, and their belief that this heightened the quality and trustworthiness of their care:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAs a teaching hospital \u0026hellip; having the Professor come in and check the work is incredibly reassuring \u0026hellip; I feel privileged to have such high-quality dental care. \u0026ndash; Participant 11\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne participant felt that the dental hospital was a better environment for care due to having communication challenges in the private sector, along with the perception that private dentistry is expensive:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI\u0026rsquo;d recommend the Dental Hospital to anyone. The private ones charge the earth and don\u0026rsquo;t explain. \u0026ndash; Participant 6\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePatients accessing public dental care were aware that the system is means-tested and oriented to provide care to the most vulnerable patients in the community, a sentiment explored in more detail within the next subtheme.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePublic System as Safety Net and Social Justice\u003c/h2\u003e \u003cp\u003eDespite the service\u0026rsquo;s orientation as a safety net service, patients acknowledged both the value this had to them personally, and also the level of care that the public system was able to provide:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI\u0026rsquo;d be in a terrible state if I hadn\u0026rsquo;t had access \u0026hellip; It\u0026rsquo;s there for a reason \u0026hellip; I think it\u0026rsquo;s an exceptionally high-quality public system. \u0026ndash; Participant 11\u003c/p\u003e\u003cp\u003eIf you can\u0026rsquo;t afford private, at least you can still get help. That means a lot when you\u0026rsquo;re on a pension. \u0026ndash; Participant 12\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants had experienced receiving outsourced care through the SEAS initiative, and also having received general dental care through the larger, state-wide Oral Health Fee For Service Scheme (OHFFSS). One participant shared that she had a poor experience with a private practitioner when accessing general care and a good experience accessing a private specialist:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe\u0026rsquo;re on a pension. I wouldn\u0026rsquo;t go back to the previous dentist (accessed on a previous general care voucher) but would definitely go back to the Specialist Endodontist. I\u0026rsquo;m very grateful. \u0026ndash; Participant 10\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSuch experiences highlight again that consistency, both between private practitioners and between private practitioners and the public sector, is an aspect of outsourcing care from public environments into the private sector that needs to be better addressed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eComparative Judgment of Private Versus Tertiary Settings\u003c/h2\u003e \u003cp\u003eWhen patients were asked about their experiences and which environment they preferred, many patients who had received a voucher to have care in the private sector stated that they were happy with the care that they received, but that they would have preferred to visit the dental hospital.\u003c/p\u003e \u003cp\u003eOne participant stated that they felt the treatment quality between public and private providers was comparable, but that the professionalism of providers at the hospital was of particular note:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf I could have had the treatment at the dental hospital, I\u0026rsquo;d have chosen it \u0026hellip; I don\u0026rsquo;t think there\u0026rsquo;s any qualitative difference in the treatment, but the reassurance and professionalism there are exceptional. \u0026ndash; Participant 11\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eClosely associated was the perception of a greater level of care and attention to detail at the hospital:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think it would be the same, but with the hospital you know they check and double-check everything. \u0026ndash; Participant 9\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother patient noted the trade-off between speed of treatment and patient journey taking longer at the hospital, but the trust and reliability of the hospital being greater.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePrivate is faster if you can find one who\u0026rsquo;ll take the voucher. But the hospital\u0026mdash;you can trust what they tell you. \u0026ndash; Participant 12\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis demonstrates the importance of understanding patient values and priorities when communicating about such schemes and the opportunity to have care outsourced into the private sector.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe NSW public system is vulnerable to loss of dental specialist capacity due to perceived disparities between the salaries provided for by the State Award and specialist earning potential in private practice. The eligible population of NSW is potentially left with little specialist coverage if existing coverage from metropolitan services is lost, and those who are based in region and remote areas suffer even greater disadvantage from lack of access [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This research demonstrates that patients were positively impacted by the establishment of a mechanism to refer specialist oral health treatment into existing private infrastructure within the community. This both increased the number of practitioners available to provide advanced specialist care, as well as allowed patients to access care nearer to where they live. The SEAS initiative represents an appropriate, patient-centred approach to addressing maldistribution of dental specialists and how engagement with the private sector can mitigate the challenge of attracting advanced dental skills capacity into the NSW public sector.\u003c/p\u003e \u003cp\u003eWhile the SEAS pathway enabled access for some participants who found contracted providers closer to home, others described substantial travel burdens, particularly where contracted sites lacked rail connectivity or were outside major transport hubs. Participants also contrasted the centrality and rail access of SDH with bus-dependent locations in the private network. Participant experiences reveal that SEAS improved access in principle but did not guarantee local convenience, with geographic benefit being variable rather than universal. This suggests that there was an inadequacy within the scheme of having enough providers with sufficient geographic distribution to fully mitigate the issue of geographic access. The uneven spatial distribution of contracted providers underscores the need for geospatial modelling in future specialist access schemes, a common theme in addressing inequitable dental access as demonstrated by previous general assessment of dental workforce distribution within Australia [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. While this could be mitigated in future iterations of the scheme, or those like it, it demonstrates the inherent maldistribution of specialist dental capacity, which is accentuated by only small numbers of potential providers being willing to participate.\u003c/p\u003e \u003cp\u003eThose accessing dental care in the NSW public system are the most disadvantaged and vulnerable in our community. Participants detailed their physical challenges, both due to disability and geography, in accessing advanced endodontic care. The narratives provided by participants in relation to the impact accessing treatment had on their wellbeing and quality of life demonstrate the importance of root canal treatment being available to patients in the public system. Recent discussion has imagined how additional dental services might be covered by Medicare [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Participants in this study were mixed in their views as to whether more complex dental treatment such as root canal treatment should be covered under a prospective scheme. This research provides additional insight into the meaningfulness of including root canal treatment within the provisions of a future expansion of oral health service provision as an essential part of holistic oral healthcare. This evaluation of the scheme also demonstrates the benefits of maintaining specialist capacity within the public sector, especially within tertiary care environments in collaboration with education and training programs. Patients detailed their perceptions of how multi-specialist teams and academic involvement in their care were significant marks of quality.\u003c/p\u003e \u003cp\u003eWhile SEAS was successful in increasing the access of patients in the NSW public sector to specialist endodontists, as highlighted earlier it is of note that only 5 specialist practitioners of the 59 registered across NSW and ACT at the time of the scheme\u0026rsquo;s establishment chose to participate. There may be several factors as to why limited specialist participation was observed, deeper understanding of this would be important for the future success of specialist access schemes in the NSW public oral health services. Participants\u0026rsquo; accounts revealed that, for some, voucher use was accompanied by stigma or transactional encounters, while others experienced respectful, high-quality interactions across both sectors. Given the program\u0026rsquo;s focus on socioeconomically eligible populations, patient dignity must be treated as a quality domain, not a by-product. Previous research has shown stigma towards public patients from private practitioners and dental students, and whilst this is by no means representative across the private sector demographic, this may be a factor in low participation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, prior investigation demonstrates that stigma relating to oral healthcare, in particular the issues of affordability, is a wider phenomenon expanding beyond the boundaries of this niche scheme [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. How this is addressed within the context of socio-economically disadvantaged patients and their experiences with accessing care in the private sector warrants further exploration in regards to future iterations of public-private oral healthcare partnerships.\u003c/p\u003e \u003cp\u003eWhile some participants detailed experiencing stigma when accessing care through private providers as public patients, the majority did not, with the main barrier to harmonious experience through the scheme being a lack of alignment between the public and private sectors. Participants frequently reported uncertainty about voucher inclusions (e.g., whether a crown was covered), post-hoc billing queries, and unclear points of contact once a voucher was issued. These pain points indicate that administrative opacity, rather than clinical care per se, was a principal source of dissatisfaction. Several participants described uncertainty about who was responsible for follow-up, defect remediation, or retreatment, particularly when a contracted clinic closed or a clinician left. Future iterations of this scheme, as well as other fee-for-service schemes referring public patients into private care should achieve improved alignment through philosophical calibration (to avoid stigmatising behaviours), ensuring the scope of the scheme is well understood, and further stakeholder engagement with private providers to improve the administration of the scheme.\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eRecommended Enhancements Based on Evaluation Results\u003c/h2\u003e \u003cp\u003eWhile this qualitative evaluation has demonstrated acceptability of the scheme to patients, the participants\u0026rsquo; experiences also allow scope for improvements that could be incorporated within future iterations of this scheme and others like it to enhance the patient journey.\u003c/p\u003e \u003cp\u003e \u003cem\u003e1) Enhance Administrative Integration and Voucher Transparency\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants reported confusion in relation to the voucher inclusion and were impacted by participating clinicians being unaware of how to use the vouchers. While patients were provided with explanatory guidance where the voucher was issued, future iterations of the scheme would benefit from providing detailed information and \u0026lsquo;frequently asked questions\u0026rsquo; to patients to help navigate the scheme. The SEAS program was articulated professionally through a policy document that was issued to participating practitioners and set out business rules for the scheme. This framework could be adapted into a patient-focused document, written in an accessible manner, to allow patients to better understand the relevant rules and inclusions of the scheme.\u003c/p\u003e \u003cp\u003e \u003cem\u003e2) Enhancing Administrative Integration\u003c/em\u003e \u003c/p\u003e \u003cp\u003eEach private dental provider is an isolated unit, being administratively and clinically separate from the rest of the healthcare system. This means coordinating a public-private partnership with private providers can be fraught with issues around organising care (e.g. provision of initial treatment direction and handover upon treatment completion). Understanding whether integrating private providers within the public sector\u0026rsquo;s administrative infrastructure in a closer manner is not a task to be undertaken lightly, however, many of the participants\u0026rsquo; experiences were marred by a lack of coordination and ability for private providers and the public sector commissioning care to effectively collaborate. Solutions within this theme could be to integrate access to public sector clinical record systems, or to establish a shared electronic workflow system for those commissioning services to better communicate with private sector dental providers.\u003c/p\u003e \u003cp\u003e \u003cem\u003e3) Enhancing Cultural Integration\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome participants reported feeling embarrassed or stigmatised when presenting vouchers to private practitioners. While this was by no means a universal experience, the scheme did not actively curate the response of private practitioners to the myriad of social and cultural relevancies that apply when providing care to socioeconomically disadvantaged patients. Due to the nature of private dentistry in Australia being self-funded (either through insurance or directly through out-of-pocket costs), private practitioners may not have competencies in managing these demographics of patients. Future iterations of the scheme could be enhanced through development of a training module for private providers, to help support them in developing \u0026lsquo;social competency\u0026rsquo;; where care can be provided to disadvantaged socio-economic and cultural groups in a safe manner. Experiences of embarrassment and transactional interactions highlight that patient dignity must be considered a measurable quality outcome. Incorporating PREMs focused on respect, communication, and inclusion would operationalise the \u0026lsquo;partnering with consumers\u0026rsquo; pillar of the Future Health Framework [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The experiences of public patients referred to private providers may also form part of future iterations of existing experience and outcome measurement tools used to evaluate public oral health services [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eAs with all qualitative research, the findings of this study are limited to the space, time and context in which the data were collected, analysed, as well as the interpretation of the research team. Different insights, experiences and themes might have emerged with a different set of participants\u0026rsquo; providing their reflections [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Despite this, the insights collected in this research have meaning and provide a valuable contribution to the literature considering different approaches to how publicly provided dental care might be organised. The sample was limited to participants willing to be interviewed, likely biasing toward those with strong experiences (positive or negative). However, the convergence observed across multiple themes strengthens the credibility of this analysis.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSEAS allowed enhanced access to complex endodontics care for patients who would have otherwise not had this care. Future public-private partnerships for specialist care will need to build on this success and develop additional scheme infrastructure to improve patient experience and outcomes. This qualitative evaluation of the SEAS initiative demonstrates how challenges in accessing specialist and specialised dental care within the public sector can be effectively ameliorated through engaging practitioners based within the private sector. Central to the benefits of this approach are high levels of patient acceptability and enhancements to the geographic accessibility of endodontic care. This scheme had the benefit of engaging smaller numbers of participating practitioners than other public-private initiatives. Scaled efforts to further access may reveal different challenges and tensions in enhancing access.\u003c/p\u003e \u003cp\u003e This research also provides insight into the importance of root canal treatment for those who receive it, with the impact to quality of life being highlighted by the participants\u0026rsquo; narratives. Future initiatives in the NSW public oral health sector that utilise this approach should further improve the administrative infrastructure used to organise and implement the provision of care to better improve patient experience. This research demonstrated the impact of receiving advanced endodontics care on the patients who shared their experiences. This highlights the importance of the public sector oral health services retaining a sufficient scope of complexity to be able to offer such clinical outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv id=\"AGS1\" class=\"AbbreviationGroupSection\"\u003e \u003cdiv class=\"Heading\"\u003eand acronyms\u003c/div\u003e \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSEAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSydney Local Health District Endodontic Access Scheme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDepartment of Veterans\u0026rsquo; Affairs\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSydney Dental Hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOHFFSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOral Health Fee For Service Scheme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eIn accordance with the Declaration of Helsinki, ethical approval for this evaluation was provided by Royal Prince Alfred Human Research Ethics Committee of Sydney Local Health District (X22-0055 \u0026amp; 2022/ETH00370). All participants provided informed consent to participate in this research.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe publication costs of this research were funded by Sydney Dental Hospital, SLHD\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAH was involved in conceptualisation of this research, ethical approval, data collection, data analysis and drafting and revision of the manuscript. ON was involved in data analysis and drafting and revision of the manuscript. Both AH and ON approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors wish to acknowledge the contribution of Shilpi Ajwani, Kim Hartley and Trupta Desai in the early stages of this research with conceptualisation and crafting of research materials. The authors also acknowledge the contribution of Daniella Beeto and Ploynaplus Srishataroon in data collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEligibility of Persons for Public Oral Health Care. in NSW [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_027.pdf]\u003c/span\u003e\u003cspan address=\"https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_027.pdf]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpecialist Registration. [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.dentalboard.gov.au/Registration/Specialist-Registration.aspx]\u003c/span\u003e\u003cspan address=\"https://www.dentalboard.gov.au/Registration/Specialist-Registration.aspx]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOral Health Fee for Service Scheme. [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2016_018.pdf]\u003c/span\u003e\u003cspan address=\"https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2016_018.pdf]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Association of Endodontists. AAE Endodontic Case Difficulty Assessment Form and Guidelines. In.; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEuropean Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J. 2006;39(12):921\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNew South Wales Ministry of Health. Future health: guiding the next decade of care in NSW 2022\u0026ndash;2032 In. St Leonards, NSW; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDillman DA. Internet, phone, mail, and mixed-mode surveys: the tailored design method, Fourth edition. edn. Hoboken, New Jersey: Wiley; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Toward good practice in thematic analysis: Avoiding common problems and be(com)ing a knowing researcher. Int J Transgender Health. 2023;24(1):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eByrne D. A worked example of Braun and Clarke\u0026rsquo;s approach to reflexive thematic analysis. Qual Quant. 2022;56(3):1391\u0026ndash;412.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qualitative Res Sport Exerc Health. 2021;13(2):201\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWillie-Stephens J, Kruger E, Tennant M. Public and private dental services in NSW: a geographic information system analysis of access to care for 7 million Australians. N S W Public Health Bull. 2014;24(4):164\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJean G, Kruger E, Tennant M. The distribution of dentists in Australia Socio-economic profile as an indicator of access to services. Community Dent Health. 2020;37(1):5\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHopcraft MS, Holden A. Australian dental practitioner attitudes to expanding Medicare to include more dental services. Aust Dent J. 2025;70(3):171\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolden ACL, Hopcraft MS. Control, access and professionalism: a qualitative evaluation of Australian dental practitioners attitudes to expanding medicare to include more dental services. 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Soc Sci Med. 2025;365:117500.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZain Ul Abideen M, Ali Bushara NA, Nadeem Baig M, Dilshad Siddiqui Y, Ejaz I, Tareen J, Siddiqui AA. Shining a Spotlight on Stigma: Exploring Its Impact on Oral Health-Seeking Behaviours Through the Lenses of Patients and Caregivers. Cureus. 2024;16(6):e63025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen R, Ajwani S, Christian B, Phelan C, Srinivas R, Kenny J, O\u0026rsquo;Connor M, Clarke K, Sohn W, Yaacoub A. The development of a new oral health patient reported outcome measure: the New South Wales public dental services approach. J Patient-Reported Outcomes. 2024;8(1):98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTonkiss F. Analysing discourse. In: \u003cem\u003eResearching Society and Culture.\u003c/em\u003e edn. Edited by Seale C. London: SAGE; 1998: 245\u0026ndash;260.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"endodontics, dental access, public-private partnership, thematic analysis, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-8154782/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8154782/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis evaluation examines patient experiences in relation to the Sydney Local Health District Endodontic Access Scheme (SEAS); an initiative run by Sydney Dental Hospital \u0026ndash; a large tertiary referral centre in NSW. The purpose of this scheme was to enhance specialist services capacity by referring advanced endodontic cases to specialist endodontists and dentists with a special interest in endodontics practising in the private sector through a novel public-private partnership.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePatients who had received a voucher for private care through this scheme were invited to participate in an in-depth interview about their experiences. Following verbatim transcription, the data were qualitatively analysed. Through thematic analysis, iterative cycles of assessment led to the emergence of themes within the data.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003e12 participants agreed to be interviewed about their experiences on the scheme. Following iterative coding, five themes emerged from the data: 1) access and timeliness of care; 2) interpersonal quality and trust; 3) clinical outcomes and aftercare; 4) voucher design, policy, and continuity of care; and, 5) equity, quality, and trust in tertiary dental hospitals.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe analysis of the participants\u0026rsquo; experiences demonstrates the ability the Sydney Local Health District Endodontic Access Scheme to address issues of access. Patients reported positive impacts on their quality of life and ability to retain function from being able to access complex endodontic care. The main area of dissatisfaction spoken about by those who had received an endodontic voucher related to the lack of integration and alignment in administration and management of the scheme between the public and private sectors. Participants who had received care through the scheme also spoke about the value of tertiary referral centres. It was specifically reported that the inconvenience of travelling to a large regional specialist centre was offset by increased trust and perceived quality compared to individual providers in private practice.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial registration\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"A Qualitative Evaluation of Patient Experiences of Receiving Endodontic Treatment Through the Sydney Local Health District Endodontic Access Scheme (SEAS)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-16 10:42:14","doi":"10.21203/rs.3.rs-8154782/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-06T04:55:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-25T21:18:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-22T11:18:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295739836199454640667269223807604816384","date":"2026-02-18T09:08:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-17T06:05:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168968889015487433297479793065450361847","date":"2026-02-15T22:01:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"278037528450331159961718159734222429428","date":"2026-02-12T05:05:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-11T06:37:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-21T10:02:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-22T06:56:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-22T06:56:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-11-19T11:27:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2df6925-912a-479a-9fc5-00b36d2f428c","owner":[],"postedDate":"February 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T16:38:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-16 10:42:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8154782","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8154782","identity":"rs-8154782","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}