How and why do health system factors influence general dentists' participation in publicly funded, contracted primary dental care services: A realist review.

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To identify health system contexts and mechanisms influencing general dental practitioners' (GDPs) participation in state funded, contracted primary oral healthcare. Peer-reviewed articles and other sources were identified via EMBASE, Medline (OVID), Web of Science and Google Scholar databases, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour, relevance and richness, and coded to identify data relating to contexts, mechanisms and outcomes. Inductive and deductive coding was used to generate context-mechanism-outcome configurations (CMOCs) and develop the final programme theory. Database searching identified 1,844 articles of which 29 were included. A further 33 sources were identified through adjunctive searches. Analysis identified key systems contexts influencing GDP participation. These include system emphasis on treatment over prevention, low priority for oral healthcare, funding constraints, and change implementation with minimal clinician consensus. At operational level, contracts can restrict GDP decision-making and ability to deliver high quality and holistic patient care. Key underlying mechanisms were feelings of ceded clinical and entrepreneurial control, stress and demoralisation, mistrust of the system and feeling undervalued. The factors influencing GDP participation in state-funded, contracted dental care over private dental care are complex. The findings presented in this review have the potential to act as a good place to start leveraging health system change including better GDP engagement and increase participation in publicly funded systems.