Download Oral Health Needs Assessment

Oral Health
Needs Assessment
(OHNA)
2012
Dr. Jasmine Murphy
Clinical Fellow in Public Health
This OHNA has been undertaken as part of the Joint Strategic Needs Assessment
Page 1 of 77
Executive Summary
Since April 2006, Primary Care Trusts (PCTs) have had the responsibility for
commissioning primary dental care and securing dental public health services to improve
oral health in their localities. From April 2013, Local Authorities (LAs) will be given the
responsibility for improving oral health for their population. At the same time, the NHS
Commissioning Board (NHSCB) will also be given the responsibility for commissioning
primary care dental services through local units. Specialist dental public health advice
will be provided by Public Health England (PHE) to NHSCB and LAs.
It is imperative that all partners understand the issues and priorities with regards to
reducing oral health inequalities, improving oral health and commissioning appropriate
NHS dental services to meet the needs of the population. This document seeks to
identify the oral health needs of the population living in Suffolk in order to provide a
strategic basis for all relevant partner organizations. However, due to time limitations,
some of the data presented (specifically in service provision) concentrates mainly on the
NHS Suffolk (NHSS) locality boundary. Demography as well as epidemiological data has
been presented for the county as a whole.
The main priorities are:
 Improving access to NHS Dentistry
 Improving oral health of the local population throughout the life-course, ensuring
that every child gets the best start in life
 Reducing oral health inequalities
 Maintaining patient safety
 Driving quality, innovation, productivity and prevention forward
In 1994, the Department of Health (DH) published An Oral Health Strategy for England1.
It defined oral health as:
“a standard of health of the oral and related tissues which enables an
individual to eat, speak and socialise without active disease, discomfort
or embarrassment and which contributes to general well-being”
This definition recognises that oral health involves more than just teeth and their
diseases, and that poor oral health has an impact upon the general health, well-being
and quality of life of individuals. Choosing Better Oral Health – An Oral Health Action
Plan for England2 identifies the actions required to deliver further oral health
improvements for the population. Whilst it is agreed that people living in England enjoy a
good standard of oral health, the gap in oral health status between those in lower and
higher socio-economic groups remains very apparent and is getting wider.
The recent oral health surveys have shown that dental health of both adults and children
has improved significantly in recent years. However, population averages mask oral
health inequalities. A well-recognised association exists between socioeconomic status
and oral health; and information suggests that oral diseases are increasingly
concentrated in the lower income and more excluded groups. Further investigations are
urgently required around access to NHS dentistry for Children in care in Suffolk. This
OHNA has also identified specific Lower-level Super Output Areas (LSOAs) as priority
1
2
Department of Health (1994): An Oral Health Strategy for England; HMSO.
Department of Health (2005): Choosing Better Oral Health, An Oral Health Plan for England; London.
Page 2 of 77
areas in targeting specific oral health interventions to reduce oral health inequalities.
Such interventions could include developing a community fluoride varnish programme
which would need to be overseen by a Consultant or Specialist in Dental Public Health.
It should also be noted that this OHNA has not covered orthodontics, sedation, minor
oral surgery, domiciliary or prison dentistry and therefore further needs assessments are
required in order to assess these areas in detail. Furthermore, Sections Six to Nine in
this OHNA has only included NHSS and further assistance is needed in understanding
and mapping the provision of services in Waveney. This expert advice and support can
be sought from PHE from April 2013 but the system should ensure adequate advisory
capacity is available for Suffolk. It should be noted that there is currently no Consultant
in Dental Public Health covering Suffolk who will transfer over to PHE.
There is a clear need to take action in improving oral health and reducing oral health
inequalities throughout the life-course for all groups in society. The level of effort
expended should be proportionate to the level of need and should focus on the wider
determinants of health. Placing oral health on an integrated agenda increases the
opportunity for the wider influences that affect oral health to be addressed more
effectively and consequently promote a more sustained improvement. Furthermore,
public health issues such as obesity, smoking, alcohol, breastfeeding share risk factors
with oral health and their underlying determinants. A common risk factor approach
provides a rationale for linking oral health improvement into the joint strategic health
improvement arena. Ultimately, as highlighted in Choosing Health5, change and
improvement can only become a reality through the public engaging and taking
responsibility for their own health. Joint agency partnership working is essential not only
in cascading appropriate consistent messages to the public, but also in addressing the
wider determinants of health such as promoting policies on clear labeling systems in
reducing the sugar content of foods and medicines and fluoridation of the public water
supply in order to progress sustainable oral health improvement.
Suffolk has an ageing population and this has significant implications on the provision of
dental services as more people will be maintaining teeth that have already been heavily
restored and therefore such locally sensitive information should be taken into account
when commissioning appropriate dental services. The evidence of clinical engagement
in commissioning is well understood and local professional networks (LPNs) are being
established to secure appropriate clinical involvement in the operational as well as the
strategic commissioning processes undertaken by NHSCB3. It is imperative that the LPN
covering Suffolk (when established) ensures that appropriate clinical dental input is
sought from lead clinicians such as dental public health specialists and dental practice
advisors.
3
NHS Commissioning Board (2012): Securing Excellence in Commissioning Primary Care; available at:
http://www.commissioningboard.nhs.uk/files/2012/06/fact-ex-comm-pc.pdf
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CONTENTS
Section Title
Page
One
Introduction
Two
Priority Setting
Three
Oral Diseases
Four
Population Profile
Five
Epidemiology of Oral Disease
Six
Dental Public Health Services
Seven Dental Service Provision
Eight
Quality of Service Provision
Nine
Patient and Public Views
Ten
Discussion
Eleven Recommendations
Glossary
5
6
13
17
22
33
41
57
62
66
74
76
Appendices
One
Two
Three
Four
Oral Health Education Action Plan 2012-14
Dental practice inspection template
Water fluoridation decision making tree
The alternatives to water fluoridation
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Section One
Introduction
Dentistry as an integral element of primary care. New contractual arrangements for NHS
dentistry were introduced in April 2006 when PCTs became responsible for local
commissioning based on oral health needs.
Improving oral health is part of the Government’s wider public health strategy and many
of the key factors that lead to poor oral health are risk factors for other diseases. Oral
health is concerned not just with teeth, but also with gums and the supporting bone and
soft tissues of the mouth, tongue and lips. Oral health is defined as:
“A standard of health of the oral and related tissues which enables an individual
to eat, speak and socialise without active disease, discomfort and
embarrassment and which contributes to general wellbeing”
(Oral Health Strategy Group, Department of Health 1994)
Although there have been significant improvements in oral health in the last 30 years,
many people still suffer pain and discomfort due to oral diseases which remain a major
public health problem. Oral diseases are largely preventable. However, despite
improvements in general, oral health for many who are vulnerable, disadvantaged and
socially excluded tend to carry a higher burden of oral diseases.
Oral Health Needs Assessment (OHNA)
An OHNA is a systematic process of examining the oral health issues of a population
which then can be used to set priorities in the allocation of resources in order to improve
oral health and reduce oral health inequalities.
This oral health needs assessment provides an overview of oral health status as well as
service provision and uptake in NHSS. It places oral health issues within the context of
national polices such as:
 Choosing Better Oral Health: An Oral Health Plan for England2
 Delivering Better Oral Health: An evidence-based toolkit for prevention4
 Valuing Peoples Oral Health: A good practice guide for improving the oral health
of disabled children and adults5
 Smokefree and Smiling: Helping patient quit tobacco6
 Improving Oral Health and Dental Outcomes: Developing the dental public health
workforce in England7
These documents have all provided a strong focus on preventive oral health, and have
supported PCTs in meeting their responsibilities for dental services. The OHNA makes
recommendations to ensure that oral health inequalities in NHSS are reduced.
4
Department of Health (2009): Delivering Better Oral Health; Product no: 283540; Gateway: 12231
Department of Health (2007): Valuing Peoples Oral Health; Product no: 284832; Gateway: 8660
6
Department of Health (2007): Smokefree and smiling; Product no: 281637; Gateway: 8177
7
Department of Health (2010): Improving Oral Health and Dental Outcomes: Developing the dental public health
workforce in England; Gateway reference: 13938
5
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Section Two
Priority Setting
Oral health improvement
The function of NHSS in terms of Dental Public Health services is clear in the
Regulations8:
‘A Primary Care Trust shall provide, or secure the provision of, the following, to the
extent that it considers necessary to meet all reasonable requirements within its
area.....oral health promotion programmes.....’
These functions will be transferred to LAs from April 2013 as one of their Public Health
responsibilites9.
The Ottawa Charter10 represents consensus agreement on good health promotion
practice and identifies the prerequisites for health, methods to achieve health promotion
through advocacy, enabling and mediation through five key action areas:
 Build healthy public policy
 Create supportive environments
 Strengthen community action
 Develop personal skills
 Reorientate health services
Choosing Better Oral Health2 supports PCTs in commissioning appropriate services to
reduce oral health inequalities. It is an action plan (linked to the wider public health
strategy Choosing Health5) designed to assist and support PCTs and the local dental
profession in addressing oral health and dental service issues. The Oral Health Plan2 is
underpinned by several principles including:
 the ‘common risk factor approach’
 basing decisions on the best available evidence
 taking a targeted population approach to reduce inequalities in oral health
 partnership working within the NHS and with education and social care
professionals
Dental disease has a large impact on individuals, society, the NHS and the wider
economy. Figure 1 shows the direct and indirect impacts of oral disease, ranging from
pain and function limitation, through to poor education performance and reduced
productivity. Furthermore, health behaviours are determined not just by knowledge but
also by social, cultural and economic factors. Figure 2 illustrates the wider determinants
of oral health.
8
Department of Health (2006): The Functions of Primary Care Trusts (Dental Public Health) Englands Regulations 2006;
available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsLegislation/DH_4138005
9
Department of Health (2011): The New Public Health System; available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131897.pdf
10
World Health Organisation (1986): Ottawa Charter for Health Promotion; WHO/HPR/HEP/95.1; Geneva
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Figure 1: Impact of Oral Diseases
Source: DH - Choosing Better Oral Health3
Figure 2: Determinants of oral health
The common risk factor approach (Figure 3) addresses risk factors common to many
chronic conditions within the context of the wider socio-environmental milieu. Oral health
is determined by diet, hygiene, smoking, alcohol use, stress and trauma. As these
causes are common to a number of other chronic diseases, adopting a collaborative
approach is more rational than one that is disease specific. The common risk factor
approach focuses preventive action on a small number of risk factors that impact on a
large number of diseases, thereby increasing the effectiveness and efficiency.
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Figure 3: Common risk factor approach
The Marmot Review11 echoes the principles of the Ottawa Charter8 with the central
ambition being the creation of conditions for people to take control over their own lives.
The starting point for the Marmot Review9 is that health inequalities that are preventable
by reasonable means are unfair and unjust; and therefore putting them right is a matter
of social justice. The concept of Proportionate Universalism, championed by the Marmot
Review9, provides a useful lens for Commissioners when tackling local health
inequalities. To reduce inequalities, action should be universal but proportionate to the
level of disadvantage and therefore an appropriate mix of whole population and targeted
interventions should be considered. The highest priority recommendation from the
Review9 was to give every child the best start in life, as disadvantage starts before birth
and accumulates throughout life.
‘Making Every Contact Count’ is a long-term strategy that aims to create a healthier
nation whilst reducing NHS costs. Putting the prevention of health problems at the heart
of every interaction between NHS staff and patients, the framework encourages frontline
staff to offer brief but appropriate advice, including ‘signposting’ services, as part of their
everyday contact with patients. It describes the generic competencies required by NHS
staff to enable them to promote healthier lifestyle choices in areas such as long-term
conditions, obesity management, smoking cessation and alcohol abuse. Furthermore,
Healthy Lives, Healthy People12 defines wellbeing as:
“a positive physical, social and mental state influenced by a range of social, cultural,
economic, psychological and environmental factors with a complex interrelationship
between mental health, physical health, environment and social inequalities”.
Therefore, NHS dentistry has an important part to play in improving the health of the
population and in reducing health inequalities throughout the life-course.
11
Marmot M. (2010): Fair Society, Healthy Lives available at: http://www.marmotreview.org/
Department of Health (2010): Healthy lives, healthy people. White Paper: our strategy for public health in England
available at:
http://www.dh.gov.uk/en/Publichealth/Healthyliveshealthypeople/index.htm
12
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Whole population
Fluoridation of public water supplies is widely used in many countries across the world. It
is a cheap and effective oral health improvement strategy in reducing oral health
inequalities for the whole population. Changes to the Water Act in 200313 put water
companies under an obligation to agree to requests from Strategic Health Authorities
(SHAs) to fluoridate their water after consultation with the local population.
Fluoridation of Drinking Water14 encourages SHAs and PCTs to consider water
fluoridation as a strategy in reducing oral health inequalities and provides best practice
guidance on the processes that need to be considered and adopted when contemplating
such a scheme. There are currently no water fluoridation schemes in operation or under
consideration within NHSS.
Targeted population
Oral health improvement programmes can be targeted and tailored to meet the needs of
specific sectors of the population. Studies have shown that they are most cost-effective
when targeted at specific communities with high levels of dental disease. There have
also been recent changes to the roles of dental care professionals. Dental nurses can
now be trained to apply fluoride varnish in dental surgeries and community settings15.
Such training would enable fluoride varnish to be applied in a cost-effective manner to
those at high risk of developing dental caries.
Oral health target
There is currently no national performance target for oral health. The last national
performance target for dental health in young children stated that:
“By 2003, five year old children should have an average of no more than one
decayed, missing or filled primary tooth; and seventy per cent of five year olds
should have no experience of tooth decay”16
The importance of dental health has been specifically mentioned in Domain 4
(Healthcare public health and preventing premature mortality) of the Public Health
Outcomes Framework (Improving Outcomes and Supporting Transparency)17 where
indicator 4.2 encourages local authorities to focus on and prioritise oral health and oral
health improvement initiatives. The indicator will focus on the rate of tooth decay in
children aged five years.
13
OPSI (2003): Water Act available at: http://www.legislation.gov.uk/ukpga/2003/37/contents
Department of Health (2008): Fluoridation of Drinking Water; Gateway: 9361
15
Primary Care Commissioning (2009): The use of fluoride varnish by dental nurses to control caries available at:
www.pcc.nhs.uk/uploads/Dentistry/.../the_use_of_fluoride_varnish.pdf
16
Department of Health (1994): An Oral Health Strategy for England.
17
Department of Health (2012): Public Health outcomes framework – Improving outcomes and supporting transparency;
available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_132558.pdf
14
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Commissioning NHS dental services
The Health and Social Care (Community Health and Standards) Act 200318 gave PCTs
the powers to commission NHS dental services to meet the needs of their local
population. These powers will be transferred to the NHSCB from April 2013. The NHS
Constitution for England19 sets out the principles and values of the NHS in England as
well as the rights which patients, the public and NHS staff are entitled to.
Dental access target
The Handbook to the NHS Constitution20 stresses the responsibility of health care
commissioners in providing NHS dental services for anyone who requires access to
them:
‘by March 2011, anyone who is seeking NHS dentistry can get it’.
A Vital Signs target was introduced in 2008 to improve access to NHS dentistry. The
target measures the increase in the number of ‘unique’ patients seen by a NHS dentist
within a 24 month period, thereby demonstrating a year on year increase in the number
of patients accessing NHS GDS. A ‘unique’ patient is classified as a patient who has not
been seen by a NHS dentist within the last 24 months in England. Each PCT has its
local trajectory. The target for NHSS is 61% of the local population accessing NHS
dental services by March 2013.
Future of NHS dentistry
The NHS in England is set to undergo its’ biggest restructuring with the abolition of
SHAs and PCTs within a very clear and set time-frame. The White Paper, Equity and
excellence: Liberating the NHS21 mentions that LAs will be given the responsibility for a
ring-fenced public health budget and ‘joint strategic needs assessments’ in order to set
local health priorities and support commissioning of appropriate services in their locality.
Furthermore, NHS dental services will be commissioned centrally through a new NHS
CB, which will also have a duty to promote equality of choice and of access to health
care. The ambition for dental commissioning is to adopt a care pathway approach and
consistency. Specialist dental public health advice will be provided by Public Health
England. Patient choice is also to be extended, with more information made public on
providers’ performance and outcomes.
A new non-departmental body, HealthWatch, is to be established within the Care Quality
Commission, to champion patients’ concerns nationally. Local divisions will be funded by
and accountable to Councils. The timeline for implementation shows that SHAs will be
abolished by 2012/13, with PCTs no longer in existence from April 2013.
18
OPSI (2003): Health and Social Care (Community Health and Standards) Act available at:
http://www.legislation.gov.uk/ukpga/2003/43/contents
19
Department of Health (2009): The NHS Constitution for England; Gateway: 13506
20
Department of Health (2010): The handbook to the NHS Constitution; Product no: 292327; Gateway: 11191
21
Department of Health (2010): Equity and Excellence: Liberating the NHS; Product no: ISBN: 9780101788120; Gateway:
14385
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New dental contract
In response to the Steele Review22, the NHS White Paper Equity and Excellence:
Liberating the NHS20 proposed the introduction of a new dentistry contract, with a
renewed focus on improving quality, achieving good dental health and increasing access
to NHS dentistry. To this end, the Government is trialling a new series of pilots in various
locations around the country. Three different contract models are being tested which will
inform the development of a new national NHS dental contract.
The proposed new dental contract will be structured to reward dentists for the continuity
and quality of care provided to patients, as opposed to Units of Dental Activity (UDAs)
delivered in the current dental contract. The DH has also published a pilot Dental Quality
and Outcomes Framework (DQOF)23 which sets out quality and outcome measures for
use in NHS dentistry. The DQOF covers four domains:
 clinical quality (which has four sub domains):
o diagnosis and treatment planning to include referrals to advanced
mandatory services
o prevention
o provision of care
o reattendance
 patient experience
 patient safety
 delivery
Consultants in Dental Public Health
Consultants in Dental Public Health (CsDPH) are dentists who have undergone higher
specialist training to provide strategic advice in the dental commissioning, oral health
improvement, patient safety, innovation and quality improvement, productivity and
clinical and public involvement.
The goals for dental public health are:
 informing the development of healthcare policy at all levels of policy-making;
 to improve the oral health and wellbeing of the population, to reduce oral health
inequalities and to make oral health services available for all and tailored to meet
the needs of each individual;
 for the wider dental team to work collaboratively with other healthcare workers
and agencies to promote health and prevent disease, including through a
common risk factor approach;
 to ensure patient safety and promote high standards of effective clinical
performance in dentistry;
 through education and training of dental and healthcare professionals and others
contributes to oral health improvement; and
 through high quality research to support oral health improvement and the delivery
and organisation of high quality, evidence-based dental care.
22
Steele J (2009): Review of NHS dental services in England available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_101180.pdf
23
Department of Health (2011): Dental Quality and Outcomes Framework; Gateway: 15285
Page 11 of 77
At present CsDPH are normally employed by PCTs and/or SHAs and work closely with
commissioning, health improvement and health protection teams. In delivering against
these programmes, CsDPH have a varied role, working with a extremely wide array of
different organisations and individuals.
CsDPH will need to continue this work across organisational boundaries in the new
healthcare structure where their ability to identify and influence key individuals locally will
be of paramount importance. In particular, they will be expected to form a close working
relationship with the NHSCB to support dental commissioning, including the
development of LPNs and implementation of new contractual arrangements currently
being piloted. They will also need to develop links with LAs to support oral health
improvement through Joint Strategic Needs Assessments (JSNA) and the oral health
component of health and wellbeing strategies.
CsDPH work closely with the rest of the dental public health team whose workforce
includes specialists in dental public health, dental practice advisors, oral health
promoters and dental epidemiologists to ensure professional leadership and
accountability. It should be noted that there is currently no CDPH covering NHSS who
will transfer over to PHE.
Dental Practice Advisors
NHSS employs 2 Dental Practice Advisors (DPAs) and NHS Norfolk & Waveney
employs 1 DPA who covers Waveney (as well as Great Yarmouth) to provide advice on
general practice dentistry. DPA duties include visiting dental practices to check on
standards of premises, equipment, infection control and other clinical issues; providing
advice on commissioning dental care under General Dental Services/Personal Dental
Services contracts/agreements, clinical governance, dealing with poorly performing
dentists, suitability for inclusion on dental registers, complaints and other general
advisory issues. Although the DPAs currently form part of the Transitional Directorate at
their relevant NHS organisations, they have reported some concern that no formal
discussions have taken place on the continual provision of their services when their fixed
term contracts end in March 2013.
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Section Three
Oral Diseases
Dental Decay (Caries)
Dental decay is the most prevalent of all oral conditions, despite being preventable. It
can occur at any age but tends to occur more frequently in the earlier years of life
particularly in lower socio-economic groups. Dental decay can reduce quality of life
through pain and infection. In very young children, decay can affect nutritional intake,
growth and weight gain24. It is therefore important for good oral hygiene habits and
dietary behaviours to be established in the formative years of life.
Gum (periodontal) disease
Gum disease is one of the most common oral diseases affecting adults but can also
present at any age. Although there has been a reduction in mild disease nationally, there
has also been an increase in the more severe form of gum disease (chronic
periodontitis). This has an impact on quality of life due to pain and infection from gum
abscesses, bleeding, halitosis (bad breath) and tooth loss. There is increased
prevalence in socially deprived groups, smokers and those with certain conditions such
as diabetes and cardio vascular disease.
Oral cancer
Oral cancer describes all malignancies of the oral cavity and throat. Anyone can develop
oral cancer, but older age groups are more at risk with 80% of those diagnosed being
over 50 years old. Men are more likely to develop oral cancer and it is more common in
socially deprived groups and those who use health services infrequently. However, the
incidence of oral cancer is rising and recent evidence shows more women and young
people being affected in recent years.
Many cases of oral cancer could have been prevented. The main risk factors are
cigarette smoking and excess consumption of alcohol. People who both drink and
smoke are over 30 times more likely to develop oral cancer than people who do not
smoke or drink. Other risk factors include dietary deficiencies, overexposure to UV light,
immunosuppression and the human papilloma viruses (HPV) which can be passed on
through oral sex.
As with any cancer, the chances of a patient surviving following diagnosis are much
greater if it is detected early. However, early presentation of oral cancer is rare due to its
painless nature in the early stages. Consequently oral cancers are usually well
advanced at diagnosis with five year survival around 50%.
24
Sheiham A. (2006): Dental caries affects body weight, growth and quality of life in preschool children. British Dental
Journal: 201 910:625-626.
Page 13 of 77
Common Risk Factors
Diet
The recent Family Food Survey25 found that a significant proportion of the population
consumes less than the recommended amount of fruit and vegetables, and more than
the recommended amount of saturated fatty acids, salt and Non Milk Extrinsic Sugars
(NMES, free sugars not bound in foods). The frequent consumption of NMES leads to
tooth decay. People from lower socioeconomic groups tend to have higher intake of
NMES. The East of England Lifestyle survey26 also reported that 41 per cent of
respondents from Suffolk consumed 5 portions of fruit or vegetables on 5-7 days per
week, with those from the more deprived areas having a lower intake.
Figure 4: East of England Regional Lifestyle Survey 2008
East of England Regional Lifestyle Survey 2008
Percentage of persons eating 5 portions of fruit and vegetables per day
with 95% confidence intervals
Residents of Suffolk County
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Eats 5
Eats 5
portions portions
<1 day
5-7 days
per week per week
20% most deprived MSOAs
Eats 5
Eats 5
portions portions
<1 day
5-7 days
per week per week
80% least deprived MSOAs
Eats 5
Eats 5
portions portions
<1 day
5-7 days
per week per week
Suffolk County
Eats 5
Eats 5
portions portions
<1 day
5-7 days
per week per week
East of England
Tobacco
Smoking is the primary cause of preventable morbidity and premature death accounting
for 18% of all deaths of adults aged 35 and over. The national ambition (Tobacco
Control Plan) is to reduce adult (over 18s) smoking prevalence in England to 18.5% or
less by the end of 2015. Smoking is also one of the biggest contributors to inequalities in
life expectancy especially in relation to cardiovascular disease, coronary heart disease,
respiratory disease and cancer. Cigarette smoking and chewing tobacco also increase
the risk of oral cancer by a factor of three, and there is evidence that exposure to
secondhand smoke also increases the risk. Tobacco increases the severity of gum
disease which leads to premature tooth loss and poor wound healing. Inequalities exist
in the prevalence of smoking with a higher rate for those living in the most deprived
25
Department for Environment, Food and Rural Affairs (2008) Family Food Survey. National Statistics Publication.
http://www.statisticsauthority.gov.uk
26
ERPHO (2008): East of England Lifestyle survey; available at: http://www.erpho.org.uk/viewResource.aspx?id=18584
Page 14 of 77
areas compared to the rest of the population. There are also differences in smoking
prevalence by occupation with a higher rate for routine and manual workers. Forest
Heath hosts the highest rates of smokers, being significantly above the national average.
Figure 5: Smoking prevalence among adults
Smoking prevalence among adults (18+), by district in
Suffolk. April 2010 - March 2011.
% of smokers
(95% confidence intervals)
Sour ce : Inte gr ate d Hous e hold Sur ve y, ONS (e xpe r im e ntal s tatis tics )
40%
30%
20%
10%
0%
Babergh
Forest
Heath
Ipsw ich
Mid
Suffolk
St
Edmund
sbury
Suffolk
Coastal
W avene
y
LA Districts
18.4%
27.2%
21.7%
18.4%
15.7%
20.9%
20.2%
Suffolk
20.1%
20.1%
20.1%
20.1%
20.1%
20.1%
20.1%
East of England
19.9%
19.9%
19.9%
19.9%
19.9%
19.9%
19.9%
England
20.7%
20.7%
20.7%
20.7%
20.7%
20.7%
20.7%
Alcohol
There is an increased level of dental caries, tooth erosion, periodontal disease and oral
cancer in people who misuse alcohol. When used in conjunction with tobacco, the risk of
developing oral cancer increases by a factor of 38.27, 28Socio-economic differentials in
drinking patterns are complex: those unemployed and on high incomes are most likely to
drink above sensible levels and to binge drink. Rates of alcohol-related mortality in
England and Wales has increased significantly in recent years, and is substantially
greater for men aged 25-49 from more disadvantaged socio-economic classes. In
2010/11, the overall rate of alcohol related hospital admissions in Suffolk showed that
Ipswich was above the national, regional and local averages.
Figure 6: Rate of alcohol related hospital admissions in Suffolk
Rate of alcohol related hospital admissions in Suffolk 2010-11. Directly
age standardised rate per 100,000 population.
Source North Wes t Public Health Obs ervatory
2250
2000
1750
1500
1250
1000
750
500
250
0
Babergh
Forest
Heath
Ipsw ich
Mid
Suf f olk
St.
Edmundsb
Suf f olk
Coastal
Waveney
LA district/borough
1527
1708
2014
1429
1801
1445
1859
Suf f olk
1681
1681
1681
1681
1681
1681
1681
East of England
1634
1634
1634
1634
1634
1634
1634
England
1898
1898
1898
1898
1898
1898
1898
27
Araujo M.W., Dermen K., Connors G. (2004): Oral and dental health among inpatients in treatment for alcohol use
disorders: a pilot study; J Int Acad Periodontol; 6:125-130.
28
Blot, W.J.et al.(1998) Smoking and drinking in relation to oral and pharyngeal cancer; Cancer Res: 48(11) 3282-7.
Page 15 of 77
Drugs
Many drugs, both prescription and illegal can affect oral health. Medications can cause
gum problems such as inflammation, bleeding or ulceration. Sugar-containing liquid
medication can also be prescribed or bought over the counter. If such medication is
taken last thing at night when the flow of saliva is reduced, the medication remains in
contact with teeth for longer which can then lead to dental decay. The British Dental
Association's view is that sugar is not a necessary or active ingredient in liquid
medicines. All front-line staff can help by prescribing or recommending sugar-free
medication where available.
The regular use of illegal drugs can also affect oral health. Prolonged drug use is often
associated with self-neglect and a diet which promotes tooth decay. In comparison with
the general population, drug users also tend to have lower utilisation of dental services.
It is estimated that there are some 2,872 opiate and/or crack cocaine users aged 15-64
in Suffolk29. Some drugs that carry a high risk to oral health include:
 Cannabis – can cause dry mouth and gum problems. The smoke can cause oral
cancer.
 Cocaine – Users sometimes rub cocaine over their gums, causing ulceration of
gums and the underlying bone. It also erodes tooth enamel and exposes the
underlying dentine to decay. Cocaine and crack cocaine cause dry mouth, which
further increases the risk of tooth decay. Cocaine also increases tooth wear by
bruxism (tooth grinding).
 Ecstasy – Side effects of the drug include bruxism, jaw clenching and dry mouth.
 Heroin – People who use heroin tend to crave sweet foods, which can increase
the risk of tooth decay if dental hygiene is neglected. Heroin can also cause dry
mouth and bruxism.
 Methamphetamine – This drug causes severe tooth decay in a very short time.
Dental professionals have coined the term ‘meth mouth’ to describe the
extensive damage typically caused by this drug. Methamphetamine is highly
acidic and attacks tooth enamel. Other side effects include dry mouth, bruxism
and jaw clenching.
Methadone is a synthetic opiate manufactured for use as a painkiller and as a substitute
for heroin in the treatment of heroin addiction. Methadone does not have the same
analgesic properties as opiates and when patients start taking methadone they often
begin to experience toothache and pain, which was previously masked by drug use, but
associate this with methadone. Methadone has a syrup like consistency and high sugar
content. It is only prescribed once a day and therefore damage to teeth should be
minimal as tooth decay is related to frequency and amount of sugar consumption.
However, opiates and opiate substitutes also cause dry mouth (a reduction in saliva
production). Saliva is a natural defence by neutralising acids in the mouth. Therefore, dry
mouth is the perfect environment for acids and sugars to attack the teeth which is
exacerbated by chaotic lifestyles with poor hygiene routines and nutrition. Methadone is
also available as a sugar free preparation and is therefore recommended as the
preferred choice.
29
National Treatment Agency (20011): Estimates of the Prevalence of Opiate Use and/or Crack Cocaine Use, (2009/10);
Sweep 6 Report
Page 16 of 77
Section Four
Population Profile
This section outlines the main features of the local population that are likely to affect the
need for particular types of oral health improvement interventions to be implemented,
and for NHS GDS to be commissioned. Understanding the structure of the population
assists in planning and commissioning appropriate dental services as oral health needs
differ between age and socio-economic groups. A previous OHNA30 which was
undertaken in 2008 provided detailed information on the demographic, social and health
profiles as well as projections at different geographic levels, age and ethnicity of the
local population living within Suffolk PCT. Therefore, only key highlights are updated in
this section.
Key population facts for the county of Suffolk:
 Half of the population (51.8%) is aged 25-64 years
 Resident population is 732,700, with a projected increase of 25.6% by 2031
(NHSS population is 602,000)
 23% of the population is 19 years and under
 27% of the population is 60 years and over
 Projected increase of 78.9% for the over 65 year age group (2031)
 The proportion of non-White British ethnic group is 10.2% (2009)
Age
The oral health needs of the population change with age and should therefore be
reflected against the age structure of the local population. Suffolk has an ageing
population which will present challenging oral health needs. The percentage of adults
with more than 21 teeth in England has increased over the last 30 years. This has an
impact for local services, as retaining teeth into later life presents increased restorative
problems and can be associated with increased periodontal disease. In addition,
complex medical conditions coupled with reduced manual dexterity and mobility can
have an impact on oral hygiene routines. These issues may restrict access to
appropriate dental provision.
Figure 7 depicts the percentage distribution of the population aged 19 years and under
by Lower-level Super Output Areas (LSOAs). It can be seen that the younger age
groups are mainly concentrated towards the towns of Ipswich, Felixstowe, Sudbury,
Havehill, Mildenhall, Bury St. Edmunds, Newmarket and Lowestoft. Figure 8 depicts the
percentage distribution of the population aged 75 years and over by LSOAs. It can be
seen that the older age groups are mainly concentrated towards the east of the county,
particularly towards the coast.
30
Murphy J (2008): An Oral Health Needs Assessment for Suffolk Primary Care Trust
Page 17 of 77
Figure 7: Percentage of population aged 19 years and under by LSOA
Figure 8: Percentage of population aged 75 years and over by LSOA
Page 18 of 77
Ethnicity
There are marked ethnic inequalities in oral health, with certain South Asian groups
experiencing more dental disease, and other Black and Minority Ethnic (BME) groups
who habitually chew tobacco or smoke heavily having increased risk of developing oral
cancers. Ethnic groups in Suffolk are in lower proportions than seen elsewhere in the
country. As a result, a lack of general awareness of specific cultural or language needs
could be preventing people from BME groups in accessing appropriate dental care.
The proportion of those in the non-White British ethnic group in Suffolk is 10.2% (2009).
The largest ethnic group in Ipswich is Asians which accounts for a third of the BME
population. Forest Heath and Ipswich have the highest non White British population. The
figure below depicts the proportion of non white British population by local authority
district/boroughs in Suffolk.
Figure 9: Proportion of non white British population by local authority district/boroughs in
Suffolk
Proportion of non white British population by local authority
district/borough in Suffolk
Source: ONS es tim ated res ident population ethnic group m id-2009
25%
20%
15%
10%
5%
0%
St
Edmundsbu
ry
Babergh
Forest
Heath
Ipsw ich
District
6.8%
21.9%
16.2%
6.4%
8.8%
7.9%
6.9%
Suf f olk
10.2%
10.2%
10.2%
10.2%
10.2%
10.2%
10.2%
Mid Suf f olk
Suf f olk
Coastal
Waveney
Disability
Individuals with disabilities experience more oral disease and have fewer teeth than the
general population. They also have greater unmet dental needs as they generally have
more difficulty in accessing dental care. Access to oral health care has shown to be
affected according to where people with learning disabilities live. Adults with learning
disabilities living in the community have greater unmet oral health needs than their
residential counterparts, and are less likely to have regular contact with dental services.
The prevalence of disability in Suffolk has been calculated based on national prevalence
estimates and is as follows:
 Learning disability: 13,218 people affected (2,851 moderate/severe)
 Physical disability: 34,860 18-64 years olds affected (10,622 severe)
 Serious visual impairment: 277 of working age; 5,364 aged 65-74 and 8,568
aged 75+
 Hearing impairment: 85,994 moderate/severe (1,800 profound)
Page 19 of 77
Gypsies and Travelers
Gypsies and Travelers experience some of the worst health of all BME groups31. There
are no local data on the oral health needs of the Gypsy and Traveler population,
although studies have demonstrated poorer dental health in this group with issues
around access to preventive dentistry.
Approximately 10% of Travelers in the Eastern region live in Suffolk (based on
proportionate caravan counts), giving a total estimated population of between 3,0005,000 Travelers in Suffolk. Twice as many Gypsies and Travelers report anxiety or
depression compared to the general population with up to 16% not being registered with
a GP.
Deprivation
The oral health needs of the local population are also associated with the socioeconomic
profile of the community. Unequal access and provision to healthcare according to need
can lead to health inequalities. Socio-economic deprivation is recognised as being the
key determinant of oral health status and therefore those living in lower socio-economic
areas tend to carry most of the burden of dental diseases in the population. There are
marked socio-economic differences within Suffolk county, as shown by the overall
pattern in the Index of Multiple Deprivation (IMD) 2010 (Figure 10).
Figure 10: IMD 2010 - Suffolk
31
NHS Suffolk (2009). Suffolk Travellers’ Health Needs Assessment 2009.
Page 20 of 77
A Classification Of Residential Neighbourhoods (ACORN) segmentation
ACORN is a geodemographic segmentation of the UK’s population which segments
small neighbourhoods, postcodes, or consumer households into 5 categories, 17 groups
and 56 types. According to the ACORN segmentation tool, the largest population groups
in NHSS are Wealthy Achievers (39%) and Comfortably Off (31%) who account for over
two thirds of the population. Compared to Great Britain, the NHSS population consists
of a larger proportions of Wealthy Achievers (39% vs 25%) and Comfortably off (31% Vs
27%) and smaller proportion of Urban Prosperity (4% Vs 12%), Moderate Means (9.7%
Vs 14%) and Hard Pressed (14% Vs 21%). The largest hard pressed group are low
income larger families which constitute 3.2% (19,612) of the population.
Figure 11: Percentage distribution of NHSS population by ACORN group
Percentage distribution of NHS Suffolk population by ACORN
group - Source: CACI 2011
45%
40%
% of households
35%
30%
25%
20%
15%
10%
5%
0%
1. Wealthy
Achievers
2. Urban
Prosperity
3.
Comfortably
Off
NHS Suffolk
39.4%
4.2%
Suffolk
38.1%
3.7%
Great Britain
24.5%
12.2%
4. Moderate
Means
5. Hard
Pressed
Unclassified
30.7%
9.7%
14.4%
1.6%
30.3%
11.6%
14.8%
1.5%
27.1%
14.0%
20.7%
1.5%
ACORN Group
Page 21 of 77
Section Five
Epidemiology of Oral Disease
Data on dental caries are regularly collected to facilitate monitoring of trends in dental
disease. The key surveys that provide information on trends in oral disease at a national
level are the decennial:
 Adult Dental Health Surveys
 Children’s Dental Health Surveys
Some data are also available at a local level from the NHS Dental Epidemiology
Programme’s (NHS DEP) rolling surveys of children’s teeth at age five years, twelve
years and fourteen years. There is a lack of local information on adult oral health and
therefore measures of child dental health are the most commonly used as a proxy for
population oral health. In addition, some conclusions can be drawn by extrapolating
national data.
The prevalence of dental caries is measured using the decayed, missing or filled tooth
index, which for deciduous (primary) teeth is denoted by dmft and for permanent teeth is
denoted by DMFT.
Child oral health
National surveys of children’s oral health are undertaken every ten years with more
frequent NHS surveys coordinated by the NHS DEP in between. The last national survey
was in 2003. These surveys show that the greatest improvement in dental health have
been observed in older children. In younger children, the greatest improvement in the
decay experience was seen between 1973 and 1983, during which time the mean dmft
per child halved and the percentage of children without any caries (caries free) doubled.
More recently, the decline has been less marked and trends suggest that disease levels
are now static or even modestly worsening. If the burden of disease in young children is
rising, this is a cause of some concern which requires more action.
Figure 12: Improvements in oral health (measured by dmft) in Children, 1973-2003
Page 22 of 77
Five-year-olds
Local data on the oral health of five-year-olds is regularly collected through the NHS
DEP by the Dental Observatory. The survey undertaken in 2007/0832 was the first that
was carried out under new arrangements24 requiring positive parental consent. The
introduction of positive consent for the survey has introduced bias and therefore the
results of this survey cannot be used for backwards comparison of trend against
previous surveys. It should be appreciated that due to sample sizes, the confidence
intervals are large and therefore the data should be interpreted with caution. The
information below also provides an example of how averages hide oral health
inequalities and further reinforces the fact that a small proportion of the local population
is experiencing a high proportion of dental disease.
Experience of dental decay at age 5


The percentage of five-year-olds in Suffolk with decay experience is lower than
the national average.
Five-year-old children living in Forest Health have the most experience of dental
decay, being above the regional average.
Figure 13: Percentage of five-year-olds with decay experience
35.0%
30.0%
25.0%
% d3mft > 0
20.0%
England
15.0%
East of England
10.0%
5.0%
B
ab
er
Fo
gh
re
st
H
ea
th
Ip
sw
ic
M
h
id
S
S
tE
uf
dm
fo
lk
un
d
S
sb
uf
ur
fo
y
lk
C
oa
st
al
W
av
en
ey
0.0%
Severity of dental decay at age 5


32
The average number of dentinally decayed, missing and filled teeth (d3mft) in
five-year-olds in Suffolk is lower than the national average.
For some children residing in Suffolk Coastal, the severity of dental decay was
slightly above the national average.
NHS DEP (2009): 2007/08 Survey of 5 year of children.
Page 23 of 77
Figure 14: Average number of dentinally decayed, missing and filled teeth in five-year-olds
1.20
1.00
0.80
Mean d3mft
0.60
England
East of England
0.40
0.20
W
av
en
ey
oa
st
al
C
S
dm
S
tE
uf
fo
lk
un
ds
bu
ry
Su
ffo
lk
id
M
h
ic
h
Ip
sw
B
Fo
re
st
H
ea
t
ab
er
gh
0.00
Extent of dental decay at age 5

The national picture shows an average of 3.45 teeth affected.
The confidence intervals show that for some children living in Babergh, Ipswich
and Suffolk Coastal, the extent of the burden of dental disease was greater than
the national average.

Figure 15: Average number of decayed, missing or filled teeth among five-year-olds who
are not free of obvious disease
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
Mean d3mft
d3mft > 0)
England
B
ab
er
Fo
gh
re
st
H
ea
th
Ip
sw
ic
M
h
id
S
Su
tE
ffo
dm
lk
un
ds
S
bu
uf
ry
fo
lk
C
oa
st
al
W
av
en
ey
East of England
Page 24 of 77
(%
Extent of dental sepsis at age 5
It is of extreme concern that the extent of dental sepsis for all 5 year old children
surveyed for all localities was above both the national and regional averages. This
indicates that dental disease is not being treated in a timely manner and the only option
for these children would be dental extractions under general anaesthesia.
Figure 16: Extent of dental sepsis among five-year-olds
10.0%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
% Abscess / Sepsis
England
F
B
ab
or erg
h
es
t
H
ea
th
Ip
sw
ic
M
h
id
S
tE S
dm u ffo
un lk
d
S
uf sb
ur
fo
y
lk
C
oa
st
a
l
W
a
ve
n
ey
East of England
Care Index
The care index is the proportion of teeth with caries experience which have been filled.
The care index should be interpreted alongside other intelligence such as levels of
deprivation, disease prevalence and the provision of dental services. Dental decay is not
equally distributed amongst the population and is strongly associated with socioeconomic deprivation. The care index is 14% across England as a whole. The care
index for Ipswich and Suffolk Coastal is lower than the national average. This indicates
that 5 years old children living in Ipswich and Suffolk Coastal are either not accessing
dental services or not receiving appropriate dental treatment.
Figure 17: Care index for five year olds
40
35
30
25
Care Index %
20
England
15
East of England
10
5
S
u
id
S
tE
dm
M
un
ds
bu
S
uf
ry
fo
lk
C
oa
st
a
l
W
a
ve
n
ey
ffo
lk
ic
h
Ip
sw
B
ab
er
gh
F
or
es
t
H
ea
th
0
Page 25 of 77
Twelve-year-olds
This survey records oral health status of the permanent (adult) dentition and was
undertaken in 2008/0933. It should be noted that 12 year old children living in the Ipswich
locality did not participate in this survey.
Experience of dental decay at age 12



33.4% of pupils nationally were found to have experience of caries by having one
or more D3MFT.
Forest Heath is above the national average with 34.1% experiencing D3MFT.
The confidence intervals show that for some 12 year olds in St. Edmundsbury
and Waveney, the experience of dental decay was also above the national
average.
Figure 18: Percentage of twelve-year-olds with decay experience
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
% D3MFT > 0
England
B
ab
er
Fo
gh
re
st
H
ea
th
Ip
sw
ic
M
h
id
S
S
tE
uf
fo
dm
lk
un
ds
S
bu
uf
ry
fo
lk
C
oa
st
al
W
av
en
ey
East of England
Severity of dental decay at age 12



33
Nationally, the average number of D3MFT per child is 0.74.
Forest Heath is above the national average at 0.78.
The confidence intervals show that some 12 year olds living in St Edmundsbury,
Suffolk Coastal and Waveney are also experiencing dental decay above the
national average.
NHS DEP (2010): 2008/09 Survey of 12 year old children.
Page 26 of 77
Figure 19: Average number of dentinally Decayed, Missing and Filled teeth in twelve-yearolds
1.20
1.00
0.80
Mean D3MFT
England
East of England
0.60
0.40
0.20
F
B
ab
or er g
es h
tH
ea
th
Ip
s
M wic
h
S id
tE S
dm uff
o
u lk
S nd
uf sb
fo
lk ury
C
oa
s
W tal
av
en
ey
0.00
Extent of dental decay at age 12
When children who are caries free are excluded, the average D3MFT nationally is 2.21.
The average D3MFT > 0 for children living in Forest Heath and Suffolk Coastal was
above the national average while the confidence intervals indicate that some children
living in Mid Suffolk and St. Edmundsbury are also experiencing dental decay levels
which are higher than the national average. Poor oral health is linked with socioeconomic deprivation and the results indicate that a polarisation in caries experience is
occurring with an increasing number of children remaining caries free and the disease
becoming concentrated in a diminishing number of socially deprived children.
Figure 20: Average number of decayed, missing or filled teeth among five-year-olds who
are not free of obvious disease
4.00
3.50
Mean D3MFT
(% D3MFT > 0)
3.00
2.50
England
2.00
1.50
East of England
1.00
0.50
B
ab
er
Fo
gh
re
st
H
ea
th
Ip
sw
ic
h
M
id
S
Su
tE
ffo
dm
lk
un
ds
S
bu
uf
ry
fo
lk
C
oa
st
al
W
av
en
ey
0.00
Page 27 of 77
Care index
The care index is 47% across England as a whole. The care index for 12 year olds living
in Suffolk Coastal is below the national average indicating that children in this locality are
not gaining the appropriate access and/or dental treatment that is required.
Figure 21: Care Index in twelve-year-olds
70%
60%
50%
Care Index %
40%
England
30%
East of England
20%
10%
B
ab
er
Fo
gh
re
st
H
ea
th
Ip
sw
ic
h
M
id
S
Su
tE
ffo
dm
lk
un
ds
S
bu
uf
ry
fo
lk
C
oa
st
al
W
av
en
ey
0%
Extractions under General Anaesthesia
General anaesthesia exposes children to unnecessary risk of complications. This is a
serious health issue which can and should be prevented. It should be noted that in
2011/12, 394 children in NHSS (aged between 18 months and 13 years) had 1,287 teeth
extracted under general anaesthetic due to dental decay.
Figure 22: Number of children requiring extractions under General Anaesthesia
Number of children requiring extractions under
General Anaesthesia
410
Number of children
400
390
380
370
360
350
2008-9
2009-10
2010-2011
Year
Page 28 of 77
2011-2012
Adult oral health
There is a lack of local information on adult oral health. Most information on adult dental
health is provided by the Office of National Statistics decennial Adult Dental Health
Survey which began in 1968. The main purpose of these surveys has been to gain a
picture of the dental health of the adult population and how this has changed over time.
The most recent survey was undertaken in 200934.
The main key points are:
 The proportion of adults in England who are edentate (no teeth) has fallen by
31% (down from 37% in 1968 to 6% in 2009)
 The prevalence of tooth decay in England has also fallen in all age groups from
46% in 1998 to 28% in 2009
 86% of dentate adults nationally had 21 or more natural teeth
 A quarter of young adults (aged 16-24 years) had no fillings
 The prevalence of periodontal disease was 45% although for the majority of
these the disease was moderate
 Over three-fifths (61%) of dentate adults said they attended the dentist for regular
check-ups
 9% of all adults reported suffering from dental pain
 7% of all adults were observed to have any PUFA35 symptoms
 12% of all adults (who had ever been to the dentist) were classified as having
extreme dental anxiety
 There is an increased need for complex dental treatment for those aged 45 years
and over
Figure 23: Proportion of edentulous adults
34
NHS Information Centre (2011): Adult Dental Health Survey 2011 available at: http://www.ic.nhs.uk/statistics-and-datacollections/primary-care/dentistry/adult-dental-health-survey-2009--summary-report-and-thematic-series
35
PUFA: Open pulp involvement, Ulceration, Fistula, Abscess
Page 29 of 77
Figure 24: Trends in percentage of dentate adults with dental caries: England 1998 to 2009
Although the survey points to an encouraging overall improvement in adults’ oral health,
this situation is not universal with untreated and unrestorable decay being present in
23% of those who reported dental pain. This serves to provide a reminder of the
association between social disadvantage and oral health. The increasing amounts of
pain reported, PUFA symptoms observed as well as the high levels of severe anxiety in
the population suggest that there are groups of people who may need special types of
care in order to return them to a pain free condition. It was also reported that those with
dental pain, PUFA symptoms and high levels of severe anxiety were more likely to be
from routine and manual occupation households. The survey also reported substantial
differences in dental attendance patterns by socio-economic classification of
households, with adults from the higher risk sections of society being more likely to
report symptomatic attendance. This reinforces the point that those from lower socioeconomic backgrounds are carrying more of the burden of dental disease but are not
seeking routine dental care.
The population as a whole is becoming less edentate with more adults retaining more
teeth further into their lives. Dental disease has lifelong impacts through the need for
continued maintenance of treatments provided, even long after the disease has been
eliminated. Therefore, although there has been a general improvement in dental health,
there is an increased need for complex dental treatment for the older population.
Dental teams are in a position to provide preventive advice not only on dental health but
also on other health matters which impact on oral health such as diet, alcohol
consumption and smoking. However only 9% of adults recalled being asked about
smoking and two thirds said they had never been asked about their diet.
The Adult Dental Health Survey also found that 75% of adults clean their teeth for the
recommended amount (twice a day), however 23% clean their teeth only once a day,
with 2% of adults cleaning their teeth less than once a day and 1% never cleaning their
teeth at all.
Page 30 of 77
Oral Cancer
Oral cancer incidence in England has risen by more than 30%29 in the last 30 years. It
has been suggested that immigration from the Indian subcontinent may have contributed
to this increase as betel nut chewing is an important risk factor. Oral cancer is 2-3 times
more common in men than women, and most cases develop in people aged 40 years or
over, with a steep rise in cases in those aged 60-65 years. However, in recent years,
incidence and mortality in young and middle-aged adults have been rising.
Trends in 1,3 and 5-year relative survival for oral cavity cancer show a significant
improvement from 1990 -2007. In this time frame, the 1-year relative survival for patients
diagnosed with oral cavity cancer in England has increased from 74% to 78% for men
and 74% to 80% for women. The 3-year relative survival has also improved, rising from
55% to 60% for men and from 58% to 68% for women. The 5-year relative survival rate
for the most recent period was reported to be 56%.
Figure 25: Trends in 1-year and 3-year relative survival for men and women in England
diagnosed with oral cavity cancer between 1990-92 and 2005-07
Source: National Cancer Intelligence Network36
Oropharyngeal cancer incidence has more than doubled in recent years, representing
the biggest rise in any head and neck cancer. Recent research suggests a change in
patterns of causation, with human papilloma virus (rather than smoking and alcohol)
being the primary risk factor in a younger subpopulation. The incidence of palate cancer
has also increased by 66% nationally. The reasons for this are unclear.
National Cancer Intelligence Network (2010): Oral Cavity Cancer – Survival Trends in England available at
http://www.ncin.org.uk/publications/data_briefings/oralcancer.aspx
36
Page 31 of 77
Men and women, diagnosed with oral cancer between 2004 and 2006, living in the least
deprived areas in England had higher 1 and 3-year relative survival than those in the
most deprived areas. The 1-year relative survival for men varied from 70% to 83%
between the most and least deprived areas in England, whereas 3-year survival ranged
from 51% to 69% respectively. For women living in the most deprived areas in England,
the 1-year and 3-year relative survival rates were 77% and 64% compared to 82% and
70% for those in the least deprived areas.
Figure 26: 1-year and 3-year relative survival for men (a) and women (b) diagnosed with
oral cavity cancer between 2004 and 2006 in England by deprivation quintile
Source: National Cancer Intelligence Network37
National Cancer Intelligence Network (2010): Oral Cavity Cancer – Survival Trends in England available at
http://www.ncin.org.uk/publications/data_briefings/oralcancer.aspx
37
Page 32 of 77
Section Six
Dental Public Health Services
Although the oral health of the UK population has improved significantly over the last 30
years, many challenges remain. As levels of health have improved, inequalities have
widened and functional and psychosocial problems associated with poor oral health are
particularly marked in already vulnerable populations such as the elderly and low income
groups.
A statutory function of PCTs is to provide or commission dental public health services.
This primarily involves dental epidemiology, dental screening and oral health promotion
activities. From April 2013, CsDPH will be located in PHE and provide advice and
support to NHSCB and to LAs. Furthermore, LAs will be responsible for sommissioning
dental public health services in their localities in order to reduce the burden of tooth
decay in their local population38. The Public Health Outcomes Framework indicator will
monitor the level of tooth decay in children aged five.
This section reports on dental public health services commissioned and delivered in
NHSS. Further information is required in understanding the provision of these services in
Waveney.
Dental Epidemiology
The NHS DEP is commissioned by DH to support the collection, analysis and
dissemination of reliable and robust information on the oral health status of local
populations. This data is essential for commissioning organisations when undertaking
OHNAs and also to report on the general oral health of their populations. Regulations
have been made under the NHS Act such that PCTs are required to undertake
epidemiology surveys. This requirement is contained in the Dental Public Health
regulations (Statutory Instruments 2006 No.185) and backed by accompanying
Directions (Directions to Primary Care Trusts concerning the exercise of dental public
health functions 2008). Therefore, under the current arrangements, PCTs are
accountable for the delivery of the NHS dental surveys.
NHSS commissions the Primary Care Salaried Dental Services (PCSDS) to undertake
this activity. This is delivered by two teams, each consisting of a dentist and a nurse
specifically trained and calibrated for each survey cycle. The team undertakes the
survey exercise as directed by the national protocol developed by NHS DEP and
forwards the cleaned, raw data to the North West Public Health Observatory (NWPHO)
for quality control, analysis and dissemination of results.
NHSS currently spends £20,000 on dental epidemiology activity from the PCSDS as part
of a block contract. This is based on the usual BASCD screening programmes for 5,12
or 14 year olds. However, it has been confirmed that for 2012/13, there will be a new
epidemiological exercise on 3 year olds. The protocol for this has not been released but
is due imminently. The exercise will commence in September 2012 and due to the
38
Department of Health (2012): Public Health Outcomes Framework; available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_132360.pdf
Page 33 of 77
nature of the exercise, the cost of running this programme for 2012/13 is estimated to
increase to approximately £60,000.
School dental screening
National guidance39,40 does not support universal screening of school age children as
previously undertaken. Any local screening programme should be designed to ensure
that positive cases are offered care and uptake of that offer should also be monitored by
an appropriate child surveillance system. Targeted ‘screening’ of at risk groups may
actually be better undertaken as a full clinical assessment rather than a screening
exercise. NHSS commissions the PCSDS to target screening activity at specifically
identified schools i.e. those with a high percentage of free school meals and all special
schools.
The number of schools screened in 2011/12 was 103, which represents 100% of the
identified schools. When a screen is positive:
i) parents of children in mainstream schools are sent a letter suggesting that a dental
visit would be appropriate with their dentist. The telephone contact for PALS is also
provided if the child does not currently attend a dental practice.
ii) parents of children in special schools are sent a letter as above and also offered an
appointment with the PCSDS.
There is currently no capacity or infrastructure in the system to monitor uptake of dental
treatment when a child is screened positive.
The dental health benefit of the school dental screening exercise is in raising awareness
of dental disease, how to access NHS dentistry and of the need for regular dental
attendance. Schools with high positive returns from the screening exercise are also
targeted by the Oral Health Education team of the PCSDS.
NHSS currently spends £30,000 on school dental screening activity from the PCSDS as
part of a block contract. NHSS should monitor the effectiveness of the school dental
screening programme using an appropriate child surveillance system which monitors the
success rates of those screened positive in taking up NHS dental care.
Oral health education (OHE)
OHE is aimed at improving oral health through the acquisition of knowledge, enhancing
motivation and seeking behavioural change. NHSS currently spends £123,000 on OHE
as part of a block contract with the PCSDS. OHE activities are delivered at whole and
targeted population groups. The OHE team is based in Bury St. Edmunds and is staffed
by 2.4 whole time equivalent (wte) members who work all year round and 1.4 wte
members who work during term time only. The team aims to increase knowledge and
change behaviour in order to improve oral health of the local population with a particular
focus on children and vulnerable adults.
39
Department of Health (2007): Dental screening (inspection) in schools and consent for undertaking screening and
epidemiological surveys; Gateway reference: 7698
40
Department of Health (2007): CDO letter to PCT CEOs; Gateway reference: 8096
Page 34 of 77
Description of OHE activities 2011/12
Targeted population groups
Children’s Programme
1. Early Years (EY):
Target population
Parents of children aged less than 5 years
Post Natal
53 groups visited: 17.6 sessions - average contact of 15 mothers per session.
Parent and Toddler/Children’s Centres
132 visits: 44 sessions - average contact of 20 parents and children per visit.
Playgroups, Nursery and Pre-school
224 visits: 74.6 sessions - average contact of 25 children per visit.
2. Schools
Target population: Children aged 5-11 (primary schools).
Years 3/4 are offered a 3 week programme related to the national curriculum. Visits are
made in response to requests from schools or as a result of a high positive school
screening rate. Teachers are always included and parents are engaged at parents
evenings. Children are provided with oral hygiene information sheets and are usually
seen more than once during their time at school.
Three sessions are offered linked in with the national science curriculum:
• session 1
o anatomy
• session 2
o nutrition and teeth
o using food wheel and games involving learning about food types
• session 3
o oral hygiene
o covers brushing of teeth and plaque disclosure (with appropriate parental
consent), including the importance of fluoride
Primary Schools
146 visits to primary and middle schools (229.6 sessions) with an average of 30 children
in each class and at least one adult member of school staff present.
Special schools
57 hours (19 sessions) with an average of 10 children in each class along with a varying
number of school staff present.
Page 35 of 77
Secondary schools
Oral health education can be provided as part of Personal, Social and Health Education.
However, where secondary schools have been approached, there has been very limited
uptake. Further partnership working is required in securing engagement with secondary
schools, especially those with a high level of free school meals.
Health days and science fairs
4 health days and 1 science fair (interactive Acid Erosion Activity developed for middle
school) delivered at various schools.
3. Colleges
6 sessions at West Suffolk College and University College Suffolk: contacts averaging
150 per session.
Vulnerable Adults’ Programme
The team has compiled a Carer’s training package that has been delivered in care
homes. These sessions are delivered on request by care homes. The requests are
usually as a result of recommendation from GDPs to carers who accompany patients to
dental practices. Some requests also come in via other healthcare teams such as
dementia services.
The sessions are based on Essence of Care41 and adheres to Delivering Better Oral
Health3, which set out key benchmarks as best practice tools for healthcare practitioners.
The sessions use photographs, toothbrushes and model teeth to demonstrate proper
methods for tooth brushing and improving oral health. The sessions are sensitive to the
confidence level of the carers themselves, and aim to address their fears and
misconceptions about oral and dental health. The sessions cover:
• plaque and gum disease
• oral hygiene instructions
• practical issues and barriers to mouth care, e.g. biting fingers, refusal or fear
• issues faced by carers of individual residents, and potential solutions
• access to dental services for residents
Other sessions
Training sessions have also been delivered to dementia services, Speech and Language
Therapists, a local children’s hospice and a local Chronic Obstructive Pulmonary
Disease sufferers group. Oral health advice and leaflets have also been provided to
drugs rehabilitation centres.
Whole population focus
The team has supported and promoted national events such as Smile Month as well as
local events such as Suffolk Show and library events. The team was also invited to join
the Healthy Ambitions Suffolk bus and has also attended a whole host of other one off
events including a Bangladeshi health awareness day, Housing association health
41
Department of Health (2010): Essence of Care; Product no: ISBN 9780113228713; Gateway ref: 14641, 14864
Page 36 of 77
event, substance misuse events, HMP Hollesley Bay and HMP Highpoint and a
selection of Youth clubs, Brownie and Rainbow groups etc. The team also signposts
patients to appropriate primary care dental services.
Evaluation
Feedback evaluation was not undertaken in 2011/12 but this has been highlighted as a
priority in the two year action plan (2012-214)42 for oral health education in going forward
(Appendix 1).
Individual preventive interventions
Fluoride varnish
Professionally applied fluoride varnish has been demonstrated to be effective in reducing
dental caries, and is recommended3 for:
 All 3-16 year olds: to be applied twice yearly
 3-16 year olds with a high risk of caries or special needs: to be applied 3-4 times
per year
OHE team
The OHE team is qualified to apply fluoride varnish under Patient Group Directives.
141.5 sessions were delivered in 2011/12 with one to one sessions of oral hygiene
instructions and fluoride varnish applications. A simple plaque score audit of these
sessions has shown an improvement in the average plaque score on patients returning
for follow up appointments of 24.8%.
General dental practitioners (GDPs)
Historically, primary care general dental services have been treatment focused. The
current dental contract was designed to encourage GDPs to focus on prevention and
health promotion. However, while the contract has removed incentives for overtreatment, there is still limited incentive for the GDP to take a more preventative
approach. Preventative activity undertaken within general dental services tends to be
largely undocumented and based on oral health education. Anecdotal evidence
suggests that this education is mainly around oral hygiene instructions with limited
advice on broader risk factors such as dietary choices, tobacco use or alcohol misuse.
GDPs have been asked to increase the number of patients who receive fluoride varnish
applications as recommended3. The rate per 100 FP17s submitted for fluoride varnish
applications shows that while the rate in NHSS has increased, it is still behind the
England average.
Table 1: Rate of fluoride varnish applications
Financial Year
2010/11
2011/12
England
2.9
4.5
42
NHSS
0.8
2.2
Murphy J., Davies C. (2012): Oral Health Education Action Plan 2012-2014; NHS Suffolk/Suffolk County Council and
Oral Health Education Department of the Primary Care Salaried Dental Services
Page 37 of 77
Fissure sealants
Fissure sealants are recommended3 for those who at high risk of developing caries (e.g.
those undergoing orthodontic treatment, those with special needs). Fissure sealants can
only be applied by dentists, therapists or dental hygienists and is therefore resource and
time intensive. The rate per 100 FP17s submitted for fissure sealants show that while
the rate in England has increased, there has been a decrease in applications locally in
the same time frame.
Table 2: Rate of fissure sealants applications
Financial Year
2010/11
2011/12
England
0.6
0.7
NHSS
0.5
0.4
Tobacco
Dentists are able to identify patients who use tobacco and who may not be in contact
with other health professionals. Tobacco is associated with a number of oral health
problems including mouth cancer. Members of the dental team therefore have an
important role in encouraging patients to quit and signposting those who smoke to stop
cessation services3,5.
NHSS has trained 25 dental practices to Level 1 and 5 dental practices to Level 2 on
smoking cessation. In 2009, dental practices received payment from NHSS Public
Health for referrals to the Stop Smoking service and 362 referrals were received. The
Stop Smoking service was then transferred to LiveWell Suffolk and referral payments to
dentists did not continue. LiveWell Suffolk has reported that in 2011, the referrals had
drastically reduced and only 85 referrals were received from dentists. Anecdotal
evidence suggests that dentists are not completely aware of the smoking cessation
services provided by LiveWell.
Alcohol
Dentists are also appropriately placed to recommend the reduction of alcohol
consumption to moderate levels and signpost patients to local alcohol misuse support
services as appropriate3. The Suffolk Alcohol Treatment Service (SATS) supports those
living in NHSS with alcohol issues and also trains individuals who come into contact with
people who may have alcohol misuse problems to deliver brief interventions and referral.
SATS does not have capacity to train dentists in this area currently and has reported not
to have received a single referral from dentists to the service. The Suffolk Drug and
Alcohol Action Team (DAAT) partnership also commissions alcohol treatment services in
the Waveney area and provides additional funding to support the work of SATS in the
NHSS area. Anecdotal evidence suggest that dentists are not aware of these services in
which to signpost patients to for assistance.
Diet
Dentists regularly investigate their patient’s diet and assist them in adopting good dietary
practice3:
Page 38 of 77




The frequency and amount of sugary food and drinks should be reduced and,
when consumed, limited to mealtimes
Sugars should not be consumed more than four times per day
Maintain good dietary practices in line with The Balance of Good Health43
Increase fruit and vegetable intake to at least five portions per day
LiveWell Suffolk is the new healthy lifestyles service commissioned by NHSS for those
living and working in Suffolk. Anecdotal evidence suggests that dentists are unaware of
this healthy lifestyles provider and therefore do not how or where to signpost patients to
the service, if required. NHSS should ensure that LiveWell Suffolk proactively engages
with the local dental profession in order to increase awareness of provision of their
service in the locality.
Breastfeeding
One of the broader aims of ante and postnatal care is to enhance the general health of
the mother. NHS dental care is free from the time pregnancy is confirmed right through
to the child’s first birthday. Delivering Better Oral Health3 recommends dentists to
encourage breast feeding as it provides the best nutrition for babies. However, anecdotal
evidence suggests that some dentists do not feel completely comfortable or confident in
discussing such issues with their patients. The opportunity to encourage the uptake of
breastfeeding should not be missed and therefore NHSS has designed a leaflet for all
pregnant and new mothers signposting them to community breastfeeding workshops in
the locality. These leaflets will be delivered to dental surgeries for display in their waiting
rooms.
Sugar-free medicines
All dentists are recommended to ensure that medication prescribed, recommended or
provided is sugar free (where available) in order to minimize cariogenic effect on teeth.
All other healthcare practitioners (GPs, nurses, midwives, pharmacists etc) should also
be adopting this recommendation. GDPs do not have a unique identifier code on their
prescriptions and therefore it is difficult to assess the level of sugar-free prescribing in
the dental profession. However, data has been obtained from NHSS Medicines
Management for prescribing data of GPs in NHSS for 2011/12 and the details are as
follows:
Table 3: GP Prescribing Data 2011/12
GP Prescribing
2011/12
NHSS
Non sugar-free
No. of items
Cost
128,821
£1,429,792.59
Sugar free
No. of items
Cost
176,625
£1,677,548.40
It is encouraging to see that the overall level of non sugar free prescribing (where there
is a suitable alternative) is lower than that of sugar-free prescribing. It should also be
noted that the overall cost of sugar free prescribing (per unit item) is cheaper at £9.50
when compared to non sugar free prescribing at £11.10. Therefore, if the 128,821 items
43
Food Standards Agency (2001): The Balance of Good Health; available at:
http://www.food.gov.uk/multimedia/pdfs/bghbooklet.pdf
Page 39 of 77
in the table above had been prescribed as sugar-free, this would have represented a
£270,408.59 cost savings to the system in 2011/12.
However, 14 main items have been highlighted which were prescribed at a much higher
rate as non sugar free when compared to their sugar free alternatives:
Table 4: Itemised GP prescriptions
GP Prescription
Item
2011/12
Gripe Water
Cimetidine_Oral
Soln 200mg/5ml
Laxido_Oral Pdr
Sach (Orange)
Ramipril_Oral Susp
2.5mg/5ml
Chlorphenamine
Mal_Oral Soln
2mg/5ml
Codeine
Phos_Linct
15mg/5ml
Simple_Linct Paed
Pseudoephed
HCl_Oral Soln
30mg/5ml
Diazepam_Oral
Soln 2mg/5ml
Clonazepam_Oral
Soln 500mcg/5ml
Methadone
HCl_Mix 1mg/1ml
Fluclox Sod_Oral
Soln 125mg/5ml
Nystatin_Oral Susp
100,000u/ml
Teething Gel
TOTAL
Non sugar-free
Sugar free
No. of
items
Cost
Cost
/item
£1.99
£25.28
No.
of
items
1
3
18
16
£35.88
£404.48
4,936
£32,165.75
4
£621.88
£0.50
£67.07
£0.50
£22.36
£6.52
1,520
£9,641.62
£6.34
1
£73.89
£73.89
2,382
£5,789.46
£2.43
459
£1,205.44
£2.63
1,637
£3,209.57
£1.96
437
£618.58
£1.42
196
80
£134.09
£103.69
£0.68
£1.30
25
66
£22.70
£85.36
£0.91
£1.29
536
£24,432.53
£45.58
23
£543.34
£23.63
36
£4,882.74
£135.63
5
£483.53
£96.71
856
£6,183.31
£7.22
532
£3,858.93
£7.25
£155.47
3,396
£100,025.47 £26.45
1,476
5,984
£107,961.80 £18.04
9
86
20,163
£95.01
£1.11
£286,045.66 £14.19
15
4,572
Cost
Cost/item
£41,435.17 £28.07
£114.08
£12.68
£31.38
£2.09
£58,181.59
£12.73
It can be seen that for some items listed above, the cost is higher (per unit item) in the
sugar free alternative. However, the overall cost per unit item of the 14 items listed is still
lower in the sugar-free alternative. These 14 items would have provided £29,370.67 cost
savings to the system.
Page 40 of 77
Section Seven
Dental Service Provision
The NHS GDS should be designed to fit closely with the needs of all sectors of the local
population whilst maximising the opportunity for those with the greatest need in receiving
appropriate dental care. The vast majority of NHS dental care in NHSS is provided in
primary care by GDPs. The PCSDS provides specialist dental treatment for special
needs groups in primary care.
In April 2006, a new contract was introduced that severed the link between items of
service provided and payments to dentists. For an agreed contract value, dentists are
now expected to deliver an agreed number of Units of Dental Activity (UDAs), which
relate to courses of treatment weighted by their complexity. UDAs are the means of
measuring performance and demand from the population against targeted activity that
has been commissioned. This section reports on dental services commissioned and
delivered in NHSS. Further information is required in understanding the provision of
these services in Waveney.
Finance
The budget for NHS dentistry was ring-fenced until the end of 2010/11. NHSS has in
place robust contract management processes where monies released from contracts
that underperform year on year are reinvested to ensure that dental access standards
are maintained for any individual who chooses to access NHS dental services. The
historical financial budget for NHS dentistry within NHSS since 2006 along with the
dental activity that has been commissioned and delivered can be seen in the table
below.
Table 5: Historical financial budget
Financial year
Financial
budget
Units of dental
activity
commissioned
Units of dental
activity
delivered
2006/07
£14.593 million
836,568
794,492
Units of dental
activity:
over(+) or
under(-)
delivery
(-) 42,076
2007/08
£15.606 million
873,364
748,915
(-)124,449
2008/09
£17.700 million
856,375
846,263
(-)10,112
2009/10
£19.765 million
913,132
889,201
(-) 23,931
2010/11
£19.793 million
992,932
930,806
(-) 62,126
2011/12
£20.199 million
980, 376
To be reported
at year end
Page 41 of 77
Programme Budgeting
Programme Budgeting is a well-established technique for assessing investment in health
programmes rather than services. It should be noted that although table 5 shows a year
on year increase in the financial budget for NHS dentistry in NHSS, the figure below
actually illustrates that expenditure on ‘dental problems’ programme per 100,000
population from 2006/07 to 2009/10 in NHSS has constantly been lower than the cluster
average.
Figure 27: Expenditure per 100,000 population on ‘dental problems’ programme,
comparing NHSS with the cluster average 2006/07 to 2009/10
Expenditure per 100,000 population for a selected programme with selected benchmark for comparison.
7.0
Suffolk PCT
Cluster average
6.0
Expenditure (£million per 100,000 population)
5.0
4.0
3.0
2.0
1.0
0.0
2006-07
2007-08
2008-09
2009-10
Financial year
Source: Department of Health, Programme Budgeting
When comparing expenditure on ‘dental problems’ programme as a percentage of total
spend, Figure 28 reiterates the fact that the spend on ‘dental problems’ in NHSS has constantly
been below the cluster, regional and national averages. Furthermore, the spend in 2009/10
was 9% lower than 2006/07. This contradicts the information in Figure 5 which shows a year on
year increase in dental spend by NHSS. This indicates that there may be some discrepancies
when information on ‘dental problems’ spend is reported back to the Department of Health.
Page 42 of 77
Figure 28: Spend on ‘dental problems’ programme on own population as a percentage
of total spend, comparing NHSS with cluster, SHA and national averages.
Proportion of total non DFT adjusted expenditure on own population
Programme spend on own population as a percentage of total spend compared to
cluster, SHA and national averages
5.0%
Note: Figures are based on non DFT adjusted expenditure on own population
4.5%
4.0%
3.5%
3.0%
.
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
2006-07
2007-08
2008-09
2009-10
Selected PCT
3.91%
3.53%
3.95%
3.82%
Cluster Average
3.95%
3.97%
4.07%
3.88%
Host SHA Average
4.10%
4.38%
4.36%
4.24%
National Average
3.86%
4.09%
4.08%
3.98%
Source: Department of Health, Programme Budgeting
When comparing spend on a programme, it is also important to consider outcomes.
Information on three dental outcomes are available within information produced by the
Yorkshire and Humber Public Health Observatory programme budgeting tool for each
PCT. The outcomes measures reported on are:
 DMFT in 12 year olds
 % of child population with a dental appointment in the last 2 years
 % of adult population with a dental appointment in the last 2 years
Figure 29 shows that although NHSS spent less financial resources on ‘dental
problems’, there has been a better outcome when considering dental disease levels of
12 year old in relation to other PCTs in England. It is important that this information is
interpreted with caution as 12 year old children living in Ipswich did not participate in the
last 12 year old dental epidemiological survey. It should be noted that for some of the
dental indicators reported in the last 12 year old survey, children in Forest Heath and
Suffolk Coastal were above the national averages.
Page 43 of 77
Figure 29: Spend and dental health outcome of 12 year olds relative to other PCTs in
England.
Spend and Outcome relative to other PCTs in England
Lower Spend,
Better Outcome
Higher Spend,
Better Outcome
2.5
2.0
Resp
1.5
Health Outcome Z Score
Gastro
Inf
1.0
Mat
Neuro
Canc
Circ
Neo
0.5
Musc
Vision
Dent
0.0
Trauma
LD
Blood,Hear,Hlth
Soc
GU
Pois Skin
End
-0.5
MH
-1.0
-1.5
-2.0
Lower Spend,
-2.5
Worse Outcome
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
Higher Spend,
Worse
Outcome
0.5
1.0
1.5
2.0
2.5
Spend per head Z Score
Source: Yorkshire & Humber Public Health Observatory
Figure 30 compares spend on ‘dental problems’ in relation to the percentage of the child
population attending a dental appointment in the last two years. This shows that
although NHSS has spent less financial resources on ‘dental problems’, there has been
a better outcome in children attending for a dental appointment in the last 2 years when
compared against other PCTs in England. However, it should be noted that the Care
Index for 5 year old children living in Ipswich and Suffolk Coastal was lower than the
national and regional averages. The Care index for 12 year olds living in Suffolk Coastal
was also lower than the regional and national average (Ipswich did not participate).
Furthermore, the extent of dental sepsis at age 5 children in the county was higher than
regional and national averages.
Page 44 of 77
Figure 30: Spend and the outcome of the percentage of child population gaining a dental
appointment in the last two years relative to other PCTs in England.
Spend and Outcome relative to other PCTs in England
Lower Spend,
Better Outcome
Higher Spend,
Better Outcome
2.5
2.0
Resp
1.5
Health Outcome Z Score
Gastro
Inf
1.0
Mat
Neuro
Canc
Circ
Neo
0.5
Musc
Vision
Trauma
Dent
0.0
LD
Blood,Hear,Hlth
Soc
GU
Pois Skin
End
-0.5
MH
-1.0
-1.5
-2.0
Lower Spend,
Worse-2.5
Outcome
-2.5
Higher Spend,
Worse Outcome
-2.0
-1.5
-1.0
-0.5
0.0
0.5
1.0
1.5
2.0
2.5
Spend per head Z Score
Source: Yorkshire & Humber Public Health Observatory
Figure 31 compares spend on ‘dental problems’ in relation to the percentage of the adult
population attending for a dental appointment in the last two years. This shows that
NHSS has spent less financial resources on ‘dental problems’ and there has been a
‘neutral’ outcome in adult dental attendance in the last two years when compared
against other PCTs in England.
Page 45 of 77
Figure 31: Spend and the outcome of the percentage of adult population gaining a dental
appointment in the last two years relative to other PCTs in England.
Spend and Outcome relative to other PCTs in England
Lower Spend,
Better Outcome
Higher Spend,
Better Outcome
2.5
2.0
Resp
1.5
Health Outcome Z Score
Gastro
Inf
1.0
Mat
0.5
Neuro
Canc
Circ
Neo
Musc
Vision
Trauma
0.0
Blood,Hear,Hlth
-0.5
LD,Dent
End
Soc
GU
Pois
Skin
MH
-1.0
-1.5
-2.0
Lower Spend,
Worse-2.5
Outcome
-2.5
Higher Spend,
Worse Outcome
-2.0
-1.5
-1.0
-0.5
0.0
0.5
1.0
1.5
2.0
2.5
Spend per head Z Score
Source: Yorkshire & Humber Public Health Observatory
It should be noted that comparisons have not been made in relation to dental health
outcome of 5 year olds and therefore the level of spend in relation to this outcome is
unknown.
Dental Access
NHSS has commissioned 82 NHS General Dental/Personal Dental Contracts, 8 NHS
Orthodontic Contracts, 11 Mixed Dental/Orthodontic Contracts and 1 domiciliary service
contract. NHS dental services within NHSS are delivered in 80 dental practices by 230
dental performers.
Figure 32 shows the location of dental practices along with UDAs commissioned against
deprivation levels in NHSS. Due to the historical nature of NHS dentistry with the old
contractual arrangements, dentists could set up an NHS practice where they wanted to
Page 46 of 77
live, not necessarily where one was needed. Therefore, it can be seen that the most
deprived areas in NHSS do not have an NHS dental practice. This is the system that
NHSS ‘inherited’ in April 2006. However, NHSS has commissioned more UDAs in
practices that are close to areas of high deprivation.
Figure 32: Map Showing NHSS IMD 2010 and Commissioned UDAs of Dental Surgeries
Figures 33 and 34 show a close-up view of the major towns in NHSS. Apart from Ipswich
and Sudbury, it can be seen that most dental practices are not located in areas of high
deprivation. However, a greater number of UDAs are being commissioned in these
areas. The PCT is responsible for providing access to dental care for all those who
choose to seek it within that PCT area. This provision of access to NHS dentistry is
therefore not solely confined to the residents of the PCT. It is not unusual for individuals
to seek dental treatment near their place of work, which could be within a different PCT
area, as opposed to where they reside. The devolution of the historical spend on
general dental services to PCTs reflected this fact.
Page 47 of 77
Figure 33: Map showing dental practices in Suffolk towns by commissioned UDAs and
deprivation level (IMD 2010)
Figure 34: Map showing dental practices in Ipswich by commissioned UDAs and
deprivation level (IMD 2010)
Page 48 of 77
The dental access standards for residents in NHSS state that individuals must be able to
access an NHS dentist within 5 miles if living in an urban area or 12 miles if living within
a rural area. The figure below shows the location of NHS dental practices (excluding
orthodontic practices) and compliance with the dental access standards by LSOA. There
is a small area to the south-west of the PCT which is not covered by the dental access
standards. However, residents in this area are currently served by practices in Haverhill
and Bury St. Edmunds.
Figure 35: Map Showing dental access standards by LSOA and location of Dental
Surgeries in NHSS
Patient Access
Figure 36 shows the proportion of all patients (adults and children) seen by GDPs within
NHSS for the 24 months ending 31 March 2006 to 24 months ending 31 March 2011. As
can be observed, there has been a general downward trend reaching the lowest point in
March 2008, followed by a plateau and a slow upward trend from September 2009 in
those accessing NHS dentistry. The picture in NHSS mirrors the national and regional
trend and could be linked to the additional investment in NHS dentistry locally.
A total of 344,594 patients were seen in the 24 month period ending March 2011 in
NHSS. This represents an increase of 11,145 on the March 2006 baseline. The
percentage of the population seen by an NHS dentist within NHSS is now above the
March 2006 level by 3.34%.
Page 49 of 77
Figure 36: Total patients seen as a percentage of the population in the previous 24 months
as at quarterly intervals
Total patients seen as a percentage of the population in the previous 24 months as at
quarterly intervals
80
70
Per cent
60
50
40
30
20
10
0
M ar- Jun06
06
Sep- Dec- M ar- Jun06
06
07
07
England
Sep- Dec- M ar- Jun07
07
08
08
Sep- Dec- M ar- Jun08
08
09
09
East of England SHA
Sep- Dec- M ar- Jun09
09
10
10
Sep- Dec- M ar10
10
11
Suffolk PCT
Data Source: Information Centre, 2011
Figure 37 demonstrates a similar picture for the proportion of adults accessing NHS
dentistry which mirrors the regional and national picture. However, it can be seen that
NHSS started off in March 2006 with more adult patients accessing NHS dentistry when
compared against the national average but has not managed to maintain this position.
Therefore, NHSS has suffered a bigger percentage loss in the system in adults attending
for NHS dental care when compared to the national picture.
Figure 37: Adult patients seen as a percentage of the adult population in the previous 24
months as at quarterly intervals
Adult patients seen as a percentage of the adult population in the previous 24 months
as at quarterly intervals
80
70
Per cent
60
50
40
30
20
10
0
M ar- Jun- Sep- Dec- M ar- Jun- Sep- Dec- M ar- Jun- Sep- Dec- M ar- Jun- Sep- Dec- M ar- Jun- Sep- Dec- M ar06
06
06
06
07
07
07
07
08
08
08
08
09
09
09
09
10
10
10
10
11
England
East of England SHA
Suffolk PCT
Data Source: Information Centre, 2011
Figure 38 shows that the proportion of children seen within NHSS is slightly above the
regional and national averages. However, the Care Index for 5 year old children showed
that those living in Ipswich and Suffolk Coastal were either not accessing care or
Page 50 of 77
receiving appropriate dental treatment. Furthermore, the Care Index for 12 year olds
also showed that those living in Suffolk Coastal were not gaining the appropriate access
and dental treatment that is required. Children in Ipswich did not participate in this study
and it is likely that they may be similarly affected. Therefore, although it is encouraging
to see that the proportion of children seen in NHSS overall is above the regional and
national average, it is likely that those living in highly deprived areas in Ipswich and
Suffolk Coastal are still facing some barriers to accessing appropriate dental care. The
inequalities mentioned is further reinforced in Figures 39 and 40 below which show that
there is a significantly lower proportion of children in care in Suffolk who have had a
dental check in the last year (2011), which is significantly below the national average.
The reasons for this require urgent investigation and attention.
Figure 38: Child patients seen as a percentage of the child population in the previous 24
months as at quarterly intervals
Child patients seen as a percentage of the child population in the previous 24 m onths as at
quarterly intervals
100
Per cent
90
80
70
60
50
40
30
20
10
0
M ar06
Jun06
Sep- Dec- M ar- Jun06
06
07
07
England
Sep- Dec- M ar07
07
08
Jun08
Sep- Dec- M ar- Jun08
08
09
09
East of England SHA
Sep- Dec- M ar09
09
10
Jun10
Suf f olk PCT
Data Source: Information Centre, 2011
Figure 39: Children in Care who have had a dental check in last year (2011)
Source: Fingertips, 2011
Page 51 of 77
Sep- Dec- M ar10
10
11
Figure 40: Children in care who have had a dental check in last year (2011)
Source: Fingertips, 2011
The PCT is responsible for providing access to dental care for anyone who seeks it.
Table 7 shows that 10% of patients treated have resided in other PCTs with 9% of
NHSS residents seeking NHS dental care outside the NHSS area. The net patient inflow into NHSS since 2005 (baseline reference year) has reduced by 41% in 2010/11
while there has been an overall increase of 21% NHSS residents gaining access to
NHS dentistry (within and outside PCT area).
Table 7: Net patient flow for NHSS since 2005
Year
05-06
06-07
07-08
08-09
09-10
10-11
Pts treated in
NHSS
274,678
280,797
278,651
283,348
296,481
301,740
NHSS residents
treated
246,142
268,873
270,974
276,474
286,703
296,636
Net inflow
Net outflow
51,235
37,616
34,566
34,166
36,406
30,473
22,699
25,692
26,889
27,292
26,628
25,369
Data Source: Dental Services NHS Business Services Authority, 2011
The dental access target for NHSS is 61% of the local population accessing NHS dental
services by March 2013. Although the percentage of patients treated in NHSS has
increased since 2006, as of March 2011 only 58.5% of the local population was
accessing NHS dentistry.
Page 52 of 77
Dental treatment
There are 3 bands of NHS dental treatment that relate to the complexity of dental care.
The number of UDAs a performer can claim ranges from 1 to 12 UDAs:
 Band 1 equates to 1 UDA and covers examination, diagnosis and preventative
dental treatment
 Band 2 equates to 3 UDAs and include Band 1 plus further treatments such as
fillings, root canal work and extractions
 Band 3 equates to 12 UDAs and includes Band 1 and 2 plus further dental
treatment requiring laboratory work
 Unscheduled urgent care equates to 1.2 UDAs under a Band 1 course of
treatment
 Issue of a prescription equates to 0.75 UDA
Figure 41: Percentage of Courses of treatment, 2010-11
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Suffolk PCT
Band 1
East of England SHA
Band 2
Band 3
Urgent
England
Other
Data source: Information Centre, 2011
The figure above indicates that NHSS has a higher proportion of COTs in Band 1 and a
lower proportion of COTs in Band 2 and 3 when compared against the regional and
national averages. A higher portion of COTs in Band 1 and a lower proportion of courses
of treatment which fall into Band 2 and 3 may reflect good overall oral health of the local
population. However, there may also be other underlying causes for fewer courses of
Band 3 treatments being offered to patients such as patients’ unwillingness to pay for
complex treatment and/or dentists being reluctant to treat patients with more
complicated needs under NHS arrangements.
Page 53 of 77
In-hours assistance with dental services
The Patient Advice Liaison Service (PALS) provides information, advice and assistance
to everyone on NHS healthcare services that have been commissioned. In terms of NHS
dentistry, PALS has traditionally provided help with:
 particular queries or concerns by liaising with health care staff in resolving
problems
 information on accessing NHS dentistry
 information on dental charges
 advice on how to make a complaint
 details of the out-of-hours service
Emergency dental appointments that are available during the working weekday hours
were commissioned in 2008 for those without a regular dentist. There are 5 appointment
slots available everyday in Bury St. Edmunds, 10 per day in Ipswich (with the exception
of Mondays when 20 are available) and 2 on Mondays in Newmarket. Other practices
within NHSS are able to offer urgent treatment if a patient is unable to travel to Bury St.
Edmunds or Ipswich. A dedicated Emergency Dental Line (EDL) was established and
this service has been managed by PALS. PALS co-ordinates the duty rota with dental
practices, negotiates extra appointments as required and also assists in managing
waiting lists for newly opened dental practice (including mobile units).
PALS have been recording the number of all dental calls received by the service since
2007. However, the service has not had the facility to code emergency dental calls
separately from other dental calls until 2011/12.
The table below shows the difference between the total and dental calls handled by
PALS. It can be seen that the majority of calls received by the service are related to NHS
dentistry. There was a 19% increase in the volume of dental calls received when the
EDL was established in 2008. These calls reached a peak in 2009/10 and has
decreased since then. This is probably due to the extra resources and investment which
were committed in 2009 in actively promoting the EDL in order to improve patient
access. Although the dental calls have reduced since 2009/10, the percentage of total
calls which relate to NHS dentistry in 2011/12 was still high at 74%. Furthermore, 43% of
dental calls received required assistance with emergency dental appointments.
Table 9: Call received by PALS
Year
Total calls to
PALS
Dental calls
received
% of total calls
that are dental
2007/08
2008/09
2009/10
2010/11
2011/12
2732
10763
16560
12827
10375
1837
9213
14087
10148
7706
67
86
85
79
74
Page 54 of 77
% of dental
calls that
require
emergency
appointments
43
The service provided by PALS is invaluable, both due to local knowledge and also the
close working relationship that has been developed with dental practices. It is therefore
of some concern that the success of this service maybe compromised in the future as
there have been no discussions as to where this service will be hosted.
Out-of-hours (OOH) dental services
PCTs are responsible for providing urgent dental care outside normal working hours.
NHSS assures that a routine NHS dental appointment is available within 6 weeks of a
patient request and within 36 hours if an urgent NHS dental appointment is required.
NHSS has commissioned the dental OOH service from Harmoni which is a triage service
only and available from 6.30pm to 8.00am on weekdays. On Monday evenings,
weekends and public holidays, a triage and treatment service operates in Bury St.
Edmunds and Ipswich. The figure below shows that the number of dental calls received
by the service has fallen by 43% from April 2011 to March 2012. The average number of
calls received in 2011/12 was 277 per month. The reasons for the drastic fall in the
number of calls received require investigation in order to ensure maximum efficiencies of
the service. One of the possible explanations could be the additional investments that
have been made in NHS dentistry locally having an effect on the need for OOH dental
care.
Figure 42: Dental calls received by OOH service provider Harmoni
Dental calls received OOH
450
400
Number of calls
350
300
250
200
150
100
50
0
Apr-11 May- Jun-11 Jul-11 Aug11
11
Sep11
Oct11
Month
Dental calls
Page 55 of 77
Nov11
Dec- Jan-12 Feb11
12
Mar12
The OOH service reports44 that the majority of emergency appointment slots available at
weekends are taken up by mid-morning. Patients attend from across the county and it
appears that provision of services in Ipswich and Bury St. Edmunds satisfies the majority
of people. The service operates from a mobile clinic and is fully staffed with four dentists
and six dental nurses covering the sessions as required. The mobile clinic is fully
equipped with digital radiography, emergency drugs, defibrillator and has a generator in
case of external power cuts. Sterilisation is outsourced to West Suffolk Hospital. The
service also receives continuous excellent feedback from patients. A snapshot audit of
patients who accessed the service was undertaken for the month of March 2012. This
showed that 235 calls were received where 151 patients (64%) required dental
assistance and were seen by the service.
Primary Care Salaried Dental Services (PCSDS)
The PCSDS provides dental services to patients across Suffolk who meet the eligibility
criteria set out below:
1
Children with disabilities and special needs including socially disadvantaged
families who are unable to access general dental practitioners
2
Children with significant/ complex medical problems
3
Children referred in with behavioural problems who otherwise would not be
able to obtain dental treatment
4
Children referred by Health or Social Care professionals
5
Children who are siblings of the above
6
Children referred for specific dental problems who require general
anaesthesia or intravenous sedation
7
Any child requiring emergency treatment who cannot access a GDP
8
Adults with special physical needs or learning disabilities unable to access
NHS dentistry
9
*Adults referred from specialist units such as drug advisor service or Blood
Born Virus team
10
*Asylum seekers and the homeless referred in by social services
11
*Adults with severe medical problems or phobias who cannot obtain
treatment from the general dental practitioner
12
*Adults with significant mental health problems who cannot access GDS
services
13
Adults who have difficulties physically accessing GDS dental services (up to
70 domicilliary visits are provided each year)
*Adults must be referred by medical, dental or other health or social care professionals
The dentists in the PCSDS review each patient’s continued eligibility at the end of a
course of treatment. The aim is to transfer patients to the General Dental Services when
appropriate.
The workforce consists of 10 dentists (5.8wte) and 1 dental therapist (0.2wte). There is
currently a vacancy of 0.4wte for a dentist/therapist. The service also employs 6 oral
health educators (2.4wte all year round and 1.4wte term-time only).
There are ten community dental clinics located across NHSS. Some clinics have
specialist facilities for wheelchair users (e.g. wheelchair platforms).
44
Gill Palmer (2012): Report to Suffolk Dental Advisory Committee
Page 56 of 77
Section Eight
Quality of Service Provision
This section reports on how quality measures are assured in NHSS. Further information
is required to understand assurance mechanisms in Waveney.
Quality of dental services
Dental Practice Inspections
DPAs carry out routine dental practice inspection visits on a regular three year rolling
programme in NHSS. The purposes of the dental inspections are to ensure that
practices are ‘Fit for Purpose’ in terms of patient safety, clinical governance, practice
management and legislative compliance. The practice visits are undertaken using a
standardized check-list (Appendix 2) and can occasionally take a day or two to
complete, depending on the issues that are found. When issues are uncovered, the
DPAs suggest changes to be implemented and return for a further inspection visit to
ensure that the changes have been made.
Dental Performers List
A dental practitioner must be listed as a performer in order to perform NHS dental
services in a primary care setting. A practitioner who is on one PCT’s Performers List
may currently perform primary care services in any PCT in England. The NHS
(Performers Lists) Regulations 2004 allows PCTs to regulate the performance of primary
medical, dental and ophthalmic services in their areas. Formally, this means that PCTs
have the power to prevent performers from performing primary care services, or to place
restrictions (conditions) on individual performers with which they are obliged to comply.
NHSS therefore has a responsibility to clearly lay out the processes and procedures to
be followed where a performer applies to be included in its performers lists and has
developed an agreed policy45 to this effect. This policy applies to all general medical
practitioners, general dental practitioners, optometrists and ophthalmic medical
practitioners who apply to become primary care performers. The aim of these
procedures is to ensure that only those performers with the relevant qualifications and
who fulfil the necessary criteria should be included in the lists thereby ensuring that
patient safety is protected.
The steps PCTs may take under the Regulations to regulate the performance of primary
care services are quite distinct from the arrangements they have for ensuring that
contractors comply with their contracts to provide services and the two systems should
not be confused. Distinction between these procedures and employment contract
procedures: where a contractor, provider or PCT employs a practitioner under a contract
of service (or contract for services), any action that is taken under the provisions of the
45
NHS Suffolk (2011): Policy for Admission to NHS Suffolk’s Medical, Dental & Optometric performers Lists; available at:
http://www.suffolkextranet.nhs.uk/LinkClick.aspx?fileticket=OENxzW7FYlI%3d&tabid=1929&mid=4427
Page 57 of 77
NHS Performers Lists Regulations 2004 does not preclude other action that may be
available under the terms of the contract.
NHSS has also developed a policy46 which specifically deals with the management of
their Performers List with regards to applications, suspensions, reviews and removals
from the Lists of primary care practitioners held by NHSS.
Supporting dental practitioners
Dental practitioners are highly competent healthcare practitioners. The provision of
excellent standards of clinical care can only be maintained by vigilance. Fundamental to
any process for identifying and managing any poorly performing primary care
practitioners is the need to:
 Protect patients and the public
 Protect colleagues and other staff
 Support practitioners
NHSS monitor dental practitioner performance closely and support practitioners who are
in difficulty in accordance with locals policies and procedures47. Various sources are
utilized including Business Services Authority (BSA) data, complaints & PALS concerns,
practice visits and patient record reviews. Serious, persistent or repeated concerns
about performance may constitute a significant risk to patients. The concerns about
clinical performance may typically relate to:
 Serious lapses in the quality of individual episodes of care.
 Persistent failure to meet explicitly required clinical standards.
 Clinical practice that deviates significantly from generally accepted national or
local norms.
The commonest reasons for complaints are due to poor communication or consultation
skills. More rarely, concerns about performance may relate to knowledge or skill,
conduct, or administration.
Serious Incidents Requiring Investigation
NHS East of England developed a policy48 based on the National Patient Safety
Agency’s (NPSA) framework for Reporting and Learning from Serious Incidents
Requiring Investigation. The NPSA has provided NHS providers with a clear framework
and their intention is that the framework can be locally embedded. The NHS East of
England policy was therefore designed to help all NHS providers take appropriate steps
in the best interests of their patients/clients/service users, staff and the NHS as a whole
and all NHS dental providers are expected to comply.
46
NHS Suffolk (2010): Policy for the Management of Performer Lists; available at
http://www.suffolkextranet.nhs.uk/LinkClick.aspx?fileticket=nQiHwrHOtFs%3d&tabid=1929&mid=4427
47
NHS Suffolk (2011): Policy for Supporting Practitioners and Protecting Patients; available at:
http://www.suffolkextranet.nhs.uk/LinkClick.aspx?fileticket=KKqM1WGL9DE%3d&tabid=1929&mid=4427
48
NHS East of England (2010): Serious Incidents Requiring Investigation Policy; available at:
http://www.suffolkextranet.nhs.uk/LinkClick.aspx?fileticket=pElUC11GXPI%3d&tabid=1929&mid=4427
Page 58 of 77
Occupational Health
NHSS commissions the full range of Occupational Health services for all dentists and
their staff. The full range includes:
 Pre-employment checks
 Immunisation (Ipswich, Newmarket and Bury St. Edmunds)
 Sickness absence (and return to work) assistance and support measures
 Ill-health retirement
 Counseling
 Physiotherapy
 Site visits for workplace assessments
 Telephone advice
Patient Complaints
NHSS/PALS assist patients and carers with any complaints or concerns that they may
have regarding any commissioned healthcare service. The figure below shows that there
has been a continual fall in the number of complaints and concerns received regarding
NHS dentistry from 2007. The number of complaints and concerns received in 2011
dropped by 26% when compared to 2007.
Figure 43: Number of complaints and concerns received about NHS dentistry by PALS
Number of complaints and concerns received about
NHS dentistry
Number of complaints and concerns
60
50
40
30
20
10
0
2007/08
2008/09
2009/10
2010/11
2011/12
Financial Year
Table 9 shows the number of complaints and concerns received from 2007 regarding
NHS dentistry according to category/issue. It can be seen that on average, over 60% of
complaints and concerns received each year (apart from 2009/10) were about clinical
issues regarding the advice, decisions and treatment that was provided).
All complaints and concerns received were successfully resolved locally apart from:
 2007/08: 1 complaint went to the Healthcare Ombudsman and was not upheld
 2008/09: 1 complaint went to Conciliation and was successfully resolved
Page 59 of 77


2010/11: 2 complaints went to the Healthcare Ombudsman – 1 complaint was
referred back to NHSS to resolve and the other complaint was not upheld
2011/12: 1 complaint went to the Healthcare Ombudsman and was not upheld
Table 9: Number of complaints and concerns received from 2007 regarding NHS dentistry
according to category/issue
Category
Description
20072008
20082009
20092010
20102011
20112012
6
3
0
6
5
0
2
5
1
0
12
11
0
8
8
0
0
18
0
1
33
28
0
25
24
0
0
0
1
0
51
44
33
41
38
Communic
ations /
attitude
A contact made either
face to face or by
telephone, fax, email or
website
and
issues
relating to verbal / nonverbal characteristics or
content
Premises
The
physical
environment of the site
occupied by the service
Practice /
Decisions made by the
surgery
practice manager about
manageme the operation of the
nt
practice (e.g. access to
individual practitioners,
appointments, opening
hours, locum cover)
General
Activities undertaken by
practice
the reception and admin
administra staff within the practice
tion
Clinical
Other
Clinical decisions, advice
and treatment provided
by a care professional
Any other issues not
covered by the above
categories
Total
Safeguarding
The dental profession has a responsibility in promoting the safety and well being of
children, young people and vulnerable adults. NHSS and Suffolk County Council (SCC)
have written guidance49 on safeguarding children and adults in general dental practice.
The guidance informs the profession about the referral pathways for cases of concern,
local points of contact for advice and training requirements. NHSS has also provided
training to the dental profession on safeguarding through the Suffolk Dental Roadshow
events.
49
Murphy J. (2012): Guidance on safeguarding children and adults in general dental practice; available at:
http://www.suffolkas.org/publications/health-publications/
Page 60 of 77
There is a duty to instruct an Independent Mental Capacity Advocate (IMCA) when a
serious medical treatment (SMT) decision needs to be made and the person lacks
capacity without anyone appropriate to consult. The role of the IMCA is to represent and
support people at times when critical decisions are being made about their health or
care. Decisions about whether or not to instruct an IMCA for dentistry decisions must be
taken on an individual basis.
The table below shows the number of actual and estimated dental referrals received to
instruct an IMCA in Suffolk. The IMCA service provider in Suffolk is Voiceability and they
have reported an issue where a residential home and the dentist could not resolve who
had the responsibility in referring for an IMCA to be instructed. The dentist claimed lack
of knowledge and the residential home claimed they were not responsible. This issue
has now been covered in the guidance on safeguarding48 to dentists.
Table 10: Number of actual and estimated dental referrals received to instruct an IMCA in
Suffolk
Year
SMT
referrals
Actual Dental
treatment referrals
2009-2010
22
not available
Estimate dental
treatment (based on
12% of SMT
referrals)
3
2010-2011
April 2011-Dec 2011 (latest)
30
17
not available
3
4
2
Page 61 of 77
Section Nine
Patient and Public Views
This section reports on patient and public views that have been gathered on NHS
dentistry in NHSS. Further information is required in understanding the views of patients
and the public in Waveney.
PALS
PALS offers a free confidential information service for patients, their families, carers and
staff who live in the NHSS area. PALS also acts as an early warning system for NHSS
by monitoring and highlighting any problems or gaps in service provision. The figure
below shows the continual increase in dental calls that have been received by the PALS
team since 2007, which peaked in 2009/10. The reason for this peak is most likely due
to the increased resources that were committed to promotional activities in sign-posting
members of the public to the PALS service in this time period. The information indicates
that quite a high proportion of the local population is still finding some difficulty in
accessing NHS dentistry without assistance from PALS.
Figure 44: Number of telephone calls received by PALS relating to NHS dentistry
11
/1
2
20
10
/1
1
20
09
/1
0
20
20
20
08
/0
9
20,000
15,000
10,000
5,000
0
07
/0
8
No. of calls
No. of telephone calls received by the service
relating to NHS dentistry
Financial year
No. of telephone calls received by the service relating
to NHS dentistry
General Practitioner (GP) Patient Survey
In 2011, there was a change in the weighting of the GP Patient Survey. Therefore, it is
not possible to make direct comparisons of the dental results with previous quarters.
Additionally the survey is also now undertaken twice yearly instead of quarterly.
Page 62 of 77
The dental access questions in the GP Patient Survey need to be considered with some
caution. The survey is sent to a sample of patients registered with a GP in Suffolk. This
does not necessarily mean that the patient surveyed is receiving dental treatment in
Suffolk, although the majority of Suffolk dentists do see patients who are living in Suffolk
and registered with a Suffolk GP.
The main results for April to September 2011 are shown in the table below. It can be
seen that although the success rate in the last 24 months is higher than the national
average, the rate for the previous 3 & 6 months was below the regional average.
Table 11: Success rates in the last 24 and 3 & 6 month periods
Success rate in last 24
months: % who
succeeded (excluding
“Can’t remembers”)
Success rate in last 3 and
6 months: % who
succeeded (excluding
“Can’t remembers”)
England
92
95
EoE SHA
94
96
NHSS
94
95
41% of respondents did not try to get an appointment with an NHS dentist in the last 2
years. The table below gives the percentage of respondents who did not try to get an
NHS dental appointment in the last two years, with the four most common reasons cited.
It is interesting to note the two reasons locally that are much higher than that observed
national response (staying with their dentist when they went private and those preferring
private dentistry). This would be consistent with the demographic profile in the ACORN
segmentation which shows a significantly higher percentage of the local population
being Wealthy Achievers when compared against the national average. Therefore, due
to bias in responding to surveys, it is unlikely that voice of those in the Hard Pressed
group has been heard.
Table 12: Four most common reasons cited for not accessing NHS dentistry
% Stayed with
dentist when
changed from
NHS to private
% didn’t think
they could get
an NHS dental
appointment
% stated they
have not
needed to go
to the dentist
% prefer to go
to a private
dentist
England
19
14
20
18
EoE SHA
20
12
19
19
NHSS
29
14
13
20
NHS Choices
NHS Choices is the online ‘front door’ to the NHS, offering public health advice and links
to local NHS services. The NHS Choices website also has a facility for patients to leave
comments/feedback on their experiences with individual providers. Table 13 provides
information about NHS dental services in NHSS that was available on the NHS Choices
Page 63 of 77
website on the 16th. April 2012. Although only half of the dental practices were accepting
new dental patients at that time, it is encouraging to see the level of provision in
extended opening times for NHS appointments.
Table 13: Information on NHS Choices
Percentage
of dental
practices
Accept
new
NHS
pts
Only
accept
children
on the
NHS
51%
24%
Offer
opening
times
after
6.30pm
(NHS)
16%
Offer
opening
times
after
6.30pm
(Private)
14%
Offering
weekend
appts (NHS)
Offering
weekend
appts
(Private)
3%
5%
The table below depicts the overall feedback received from patients regarding dental
treatment received at 23 dental practices in NHSS. There were no patient feedback
information for 52 dental practices. NHSS receives copies of all postings for NHS dental
practices as they are published and appropriate action is taken when a negative
comment is received to ensure that the issue/s highlighted have been resolved (where
appropriate).
Table 14: Patient feedback on NHS Choices
Percentage of feedback
received for 23 dental
practices
Would recommend to a
friend
NHS = 32%
Would not recommend to
a friend
NHS = 18%
Private = 5%
Private = 5%
NHS BSA Dental Services Division (DSD)
NHS DSD include in their Vital Signs report details of the percentage of patients satisfied
with the dentistry they have received and the percentage of patients satisfied with the
time they had to wait for an appointment. The figures below the results of both indicators
from June 2010 to March 2012.
Figure 45 shows patient satisfaction rates on the dental service they have received. It
can be seen that although the satisfaction rate has increased from 92.4% to 94.6% for
Suffolk, it actually started off above the national and regional averages and is now below
the regional average. Therefore, the increase in patient satisfaction has not mirrored the
increase observed nationally or regionally. The reasons for this require further
investigation.
Page 64 of 77
Figure 45: Percentage of patients satisfied with the dentistry they have received in NHSS
% of patients satisfied with the dentistry they have
received
96
95
Percentage
94
93
92
91
90
ug
-1
0
O
ct
-1
0
D
e
c1
0
F
eb
-1
1
A
pr
-1
1
Ju
n1
1
A
ug
-1
1
O
ct
-1
1
D
e
c1
1
F
eb
-1
2
A
Ju
n1
0
89
Time
Suffolk
East of England
England
Figure 46 shows patient satisfaction rates on the time they had to wait for a dental
appointment. It can be seen that although Suffolk started off being above the national
and regional average, the increase in patient satisfaction with this indicator is consistent
with the regional and national average.
Figure 46: Percentage of patients satisfied with the time they had to wait for an
appointment in NHSS
% of patients satisfied with the time they had to wait for an
appointment
92
91
89
88
87
86
85
Time
Suffolk
East of England
Page 65 of 77
England
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
84
Jun-10
Percentage
90
Section Ten
Discussion
Main priorities





Improving access to NHS Dentistry
Improving oral health of the local population throughout the life-course,
ensuring that every child gets the best start in life
Reducing oral health inequalities
Maintaining patient safety
Driving quality, innovation, productivity and prevention forward
This OHNA has examined oral health status, need and provision of general dental
services in NHSS. Further information is required in understanding the full level of need
and provision of services in Waveney. This OHNA has not covered orthodontics,
sedation, minor oral surgery, domicillary or prison dentistry and therefore further needs
assessment will need to be undertaken to assess these areas in detail. A Consultant or
Specialist in Dental Public Health has the expertise to undertake such examination of
need for the local population. This OHNA has been undertaken by a Specialist in Dental
Public Health but NHSS does not currently employ a CDPH who will transfer to PHE.
The recent oral health surveys have shown that dental health of both adults and children
has improved significantly in recent years. However, population averages mask oral
health inequalities. A well-recognised association exists between socioeconomic status
and oral health and information suggests that oral diseases are increasingly
concentrated in the lower income and more excluded groups. There is also a strong
association between oral health and other lifestyle factors including smoking, alcohol,
diet and substance misuse.
Child oral health
The Marmot Review6 recommends giving every child the best start in life. Suffering from
caries in childhood is the strongest predictor for suffering from caries later in life. Sir Ian
Kennedy's report50 on healthcare services for children and young people reinforced the
urgency to focus on children's services across health and social care. The
consequences of suffering from dental caries for children include severe pain, loss of
self esteem, developing fear/anxiety towards dental treatment, sleep loss for patients
and parents/carers and also poor educational performance due to time off school with a
further impact on the time taken off work for parents.
Whilst the national surveys of children’s oral health show great improvement in dental
health, they also indicate that most of the improvements are observed in older children
and that the burden of disease in young children may be rising. This is a cause of some
concern which requires action.
50
Kennedy I. (2010): Getting it right for children and young people, overcoming cultural barriers in the NHS to meet their
needs. Available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_119446.pdf
Page 66 of 77
The latest 5 year old children’s survey shows that the extent of dental sepsis among five
year old children in Suffolk is higher than the national and regional averages.
Furthermore, the care index for 5 years olds living in Ipswich and Suffolk Coastal is
lower than the national and regional averages. The care index for 12 year olds living in
Suffolk Coastal is also below the national and regional averages. Whilst the care index
for 12 year olds living in Ipswich is not known, it is likely that it will be in line with the
observations for the 5 year olds. When looking at dental disease levels for 12 year olds,
Forest Heath, Waveney, St. Edmundsbury and Suffolk Coastal are above national
average for some of the indicators. Furthermore, in 2011/12, 394 children required 1,287
extractions of teeth under general anaesthesia due to dental decay. It should also be
noted that Suffolk is a significant outlier when children in care are assessed for dental
checks in 2011. There are oral health inequalities for children in Suffolk.
Further analysis on the demographic profile shows that almost a quarter of the
population living in Suffolk (23%) is under the age of 19 years. Figures 7 and 10 show
the percentage distribution of Suffolk population by age group (under 19 years) and also
IMD by LSOA. The figure below has superimposed the main areas of highest deprivation
and concentration of children population in Suffolk in order to define specific priority
areas for targeting of appropriate interventions to reduce oral health inequalities for
children.
Figure 47: LSOAs showing overlap where a large proportion were children aged 19 years
and under (24% to 46%) and the area featured in the 20% most deprived LSOAs in Suffolk
The table below shows the defined LSOAs as priority areas for targeting of appropriate
interventions to reduce oral health inequalities for children. There are no LSOAs in Mid
Suffolk that have been highlighted.
Page 67 of 77
Table 15: Defined LSOAs according to district and borough councils
Babergh
E01029889
E01029910
E01029914
E01029916
Forest
Heath
E01029938
Ipswich
St. Edmundsbury
E01029979
E01029980
E01029982
E01029984
E01029986
E01029987
E01029993
E01029994
E01029996
E01029998
E01030018
E01030022
E01030026
E01030029
E01030031
E01030032
E01030035
E01030109
E01030114
E01030115
E01030118
E01030123
E01030131
Suffolk
Coastal
E01030168
Waveney
E01030234
E01030246
E01030248
E01030249
E01030250
E01030254
E01030255
E01030261
E01030264
E01030265
E01030279
E01030291
Adult oral health
Both the Steele Review20 and the 2009 ADHS25 have identified that different cohorts of
patients require different types of dental treatment throughout their life-span. However,
although it has been reported that there have been significant improvements in oral
health, there are still those suffering with extensive dental disease. In addition, dental
needs can be very complex for those in older age as people are keeping their teeth for
longer. There is also a significant proportion of adults who require special care due to
extreme dental anxiety. A small proportion of the population will also never access
dental services. Oral health inequalities for adults will continue to exist in Suffolk if not
addressed appropriately.
Those from lower socio-economic backgrounds not only carry more of the burden of
dental disease, but are also more at risk from developing oral cancer. The incidence rate
in oral cancer has increased nationally. The differing risk factors of certain groups need
to be considered. The older age group (particularly those from deprived backgrounds),
certain ethnic groups and those who seek dental assistance on an irregular basis are
more at risk from developing oral cancer. The largest ethnic group in Ipswich is Asians
which accounts for a third of the BME population. The principal risk factors for oral
cancer are smoking, alcohol and chewing of betel quid. The latter, by immigrants from
the Indian sub-continent, may have partly contributed to the rising trend of oral cancer
and therefore this group should be targeted for appropriate interventions in order to
reduce oral health inequalities.
Figures 8 and 10 show the percentage distribution of Suffolk population by age group
(over 75 years) and also IMD by LSOA. The figure below has superimposed the main
areas of highest deprivation and concentration of older population in Suffolk in order to
define specific priority areas for targeting of appropriate interventions to reduce oral
health inequalities in the older population.
Page 68 of 77
Figure 48: LSOAs showing overlap where a large proportion were adults aged 75 years
and over (13% to 29%) and the area featured in the 20% most deprived LSOAs in Suffolk
The table below shows the defined LSOAs as priority areas for targeting of appropriate
interventions to reduce oral health inequalities for the older population. There are no
LSOAs that have been highlighted for Forest Heath, St. Edmundsbury and Mid Suffolk.
Table 16: Defined LSOAs according to district and borough councils
Babergh
E01029886
E01029920
Ipswich
E01030012
E01030013
E01030014
E01030036
Suffolk Coastal
E01030162
E01030170
Waveney
E01030225
E01030247
E01030257
E01030263
E01030274
E01030287
It should be mentioned here that there has been a failure to appoint a substantive Oral
and Maxillofacial Surgery (OMFS) Consultant post which has been vacant for more than
two years at the Ipswich and West Suffolk Hospitals. The current OMFS service is led by
1 OMFS Consultant and supported by middle grade and junior staff. A sustainable model
for OMFS service delivery needs to be developed which ensures appropriate cover for
head and neck cancer and maxillofacial trauma in Suffolk51.
51
Murphy J. (2011): Oral and Maxillofacial Surgery Service Provision in NHS Suffolk
Page 69 of 77
Oral Health Improvement
Oral health education (OHE) is aimed at improving oral health through the acquisition of
knowledge, enhancing motivation and seeking behavioural change. OHE has been
considered the panacea that would provide people with better oral health. However,
accumulating evidence reveals that solely focusing on individual behaviour without
tackling the wider determinants of health does not reduce health inequalities. Oral Health
Promotion (OHP) is an enabling process in developing lifelong sustainable attitude and
skills. It comprises a range of complementary approaches including building healthy
public policy, creating supportive environments, strengthening community action,
reorienting health services and developing personal skills. The success of these
approaches largely depends upon multi-sectoral working.
There are currently no OHP programmes in Suffolk and therefore this OHNA has been
undertaken as part of the Joint Strategic Needs Assessment (JSNA) in order to influence
the Health and Wellbeing Strategy (HWS) for a Suffolk Oral Health Strategy (OHS) to be
developed in collaboration with all partners.
NHSS commissions OHE from the PCSDS but there is currently no routinely collected
quantitative data on the effectiveness of the OHE programme that is being delivered. It is
appreciated that outcomes data is difficult to quantify for health improvement
programmes and tends to have a time lag of many years. However, there are a few
principles with regards to OHE delivery that could possibly be improved particularly with
regards to:
 Ensuring that OHE starts during pregnancy.
 More engagement with BME groups.
 Providing cascade training sessions aimed at Health visitors and Children’s
Centre staff to enable them to deliver OHE to children and parents.
 Routinely emphasising smoking cessation and alcohol reduction.
 Partnership working with LiveWell, SATS and the DAAT, particularly with regards
to addressing oral cancer awareness.
 Supporting multi-sectoral approaches to OHE.
 Evaluation of the OHE programme/s.
Some of the points raised above have been addressed by the PCSDS in the 2012-2014
OHE Action Plan41. However, a more co-ordinated approach with multi-agency
partnerships requires a strategic approach in addressing the wider determinants of
health throughout the life-course. Major shifts in public policy such as taxes to control
soaring consumption of sugar and sweeteners and fluoridation of the public water supply
should be considered. A decision making tree has been drafted52 to assist LAs and
PCTs in considering whether a feasibility study on water fluoridation should be
undertaken (Appendix 3). In areas where water fluoridation is not feasible, there are
specific fluoride interventions that can be considered for the population53 (Appendix 4).
The Department of Health considers the application of fluoride varnish to be ‘one of the
best options for the application of topical fluoride to teeth in the absence of water
fluoridation’. The provision of a community/outreach preventive programme which
includes the application of fluoride varnish would therefore be appropriate for certain
population groups. The General Dental Council (GDC) has also confirmed that dental
52
53
Murphy J. (2009): Water fluoridation decision making tree
Murphy J. (2009): The alternatives to water fluoridation
Page 70 of 77
nurses may apply fluoride varnish after appropriate training and as part of a programme
which is overseen by a Consultant or Specialist in dental public health. Such a
programme would increase the skill-mix in harnessing the opportunity to address health
inequalities in the population.
Individual preventive interventions are available (fluoride varnish and fissure sealant
applications in particular) and these interventions are being delivered by the PCSDS and
also by GDPs. However, the rate of fluoride varnish applications in NHSS is half of that
observed nationally. Furthermore, whilst the rates of fissure sealant applications have
increased nationally, this rate has decreased locally. The applications of fluoride varnish
and fissure sealants are recommended in the evidence-based toolkit for prevention3.
Therefore, the local dental profession should be encouraged to increase their delivery of
these interventions in order to improve oral health for the population.
GDPs should also be using the common risk factor approach and providing preventive
advice for tobacco, alcohol and diet. Questions about tobacco, diet and alcohol
consumption are commonly included in dental patient medical history questionnaires.
Asking health related questions, however, does not necessarily mean that the dental
team is acting on the information given by patients. This may reflect reluctance or lack of
confidence in providing such advice. Additionally, dietary advice delivered by dental
teams has traditionally had a narrow focus, not always consistent with general health
advice55. Therefore such advice may be more effective if it is integrated into general
health advice55. It would be appropriate to ensure that all GDPs are aware of the general
preventive services that are available locally (i.e. Smoking Cessation, Healthy Lifestyle,
Alcohol as well as Substance Misuse) in order for dentists to be able to sign-post
patients appropriately. This would also be consistent with ‘making every contact count’.
The Government has announced their intention to introduce a "health premium"
incentive scheme where Councils which gain the best results across 60 factors
influencing health will be awarded extra funds. This incentive scheme has not been
finalised and it is likely that it will be a few years before it is introduced. However, it has
been suggested that some of the Public Health outcome indicators tied to the Public
Health premium are likely to be: child tooth decay, childhood obesity, breast feeding,
falls in over 65s, smoking prevalence, heart disease and stroke. This adds further weight
for oral health to be included as a priority area in the JSNA and HWS in order for an
OHS to be agreed between all partner agencies. Placing oral health on a wider agenda
for change will enable joint projects to be developed that will secure wider commitment
and help achieve long-term sustainability and effectiveness.
Providing GPs with the right information and support on prescribing can also realistically
deliver savings for Clinical Commissioning Groups (CCGs) in their prescription budgets.
There is an opportunity in cost savings within the CCGs prescribing budgets if the level
of sugar-free alternatives are increased. If these cost savings are released, it will enable
CCGs to retain and develop services as well as improving the oral health of the local
population. As demonstrated in table 3, there was an opportunity for £270,408.59
savings in the system if sugar-free alternatives had been prescribed in 2011/12.
Page 71 of 77
Oral Health Services
Although there has been a year on year increase in the financial allocation for NHS
dentistry locally, programme budgeting shows that the expenditure on ‘dental problems’
per 100,000 population in NHSS has constantly been lower than the cluster, regional
and national averages. When comparing spend against outcome, better outcomes for
NHSS has been reported for 12 year old dental health status and also on the percentage
of the local child population in accessing NHS dentistry within the last 2 years. However,
as mentioned previously, the outcome on 12 years old dental health status is not valid as
children in Ipswich did not participate in the survey and therefore bias has been
introduced. Furthermore, 12 year old children in Forest Health and Suffolk Coastal were
higher on some of the dental indicators against the national average (as reported in the
local surveys). The level of spend has not been assessed against dental health outcome
for 5 year olds and therefore comparison of spend against this outcome is not known.
There is also a ‘neutral’ outcome for the percentage of the local adult population in
accessing NHS dentistry relative to other PCTs in England. The evidence of this
information is reiterated in figure 37, which shows NHSS performing on par with the
regional and national averages when assessing adult patients attending for NHS dental
treatment. It can be seen that as spending has increased year on year, there has been
an improvement in adults accessing NHS dental services locally. The dental access
target for NHSS is 61% of the local population accessing NHS dental services by March
2013. It is highly unlikely that this target will be met.
Figures 32, 33 and 34 show the location of dental practices according to the level of
UDAs commissioned and IMD. It can be seen that the areas of highest deprivation are
mostly centred near the main towns, where there appears to be adequate provision of
NHS dental services. However, figure 35 shows the coverage of NHSS in complying with
the dental access standard. Although the coverage is good overall, there is one LSOA in
St. Edmundsbury (E01030099) which does not meet the dental access standard. The
1,869 people living in this rural area are traveling further to access NHS dental services.
When analysing the level of dental treatment bandings that have been provided to
patients, it has been demonstrated that there is a higher level of Band 1 courses of
treatment and a lower level of Band 2, Band 3 and Urgent courses of treatment when
compared to both the regional and national averages. The reasons for this need to be
investigated further.
The number of dental calls received by PALS shows that approximately three in four
calls received are regarding NHS dentistry. Approximately 1 in 2 dental calls received
require assistance with emergency dental appointments. For OOH assistance with
dental services, information shows that the number of calls received by Harmoni has
fallen by about half since commencement of the service in April 2011. The reasons for
this should be explored. Further investigation into whether patients are actually
accessing other services for urgent dental care should be considered i.e. accident and
emergency departments etc and this information should be sought. It is important to
ensure that the OOH service that is commissioned reflects the need of the local
population.
The number of complaints or concerns received by NHSS about NHS dental services
has fallen by 26% in 2011/12 when compared to 2007/08. Over 60% of complaints every
Page 72 of 77
year have been about clinical issues regarding advice, decisions and treatment that was
provided. This information may support the Office of Fair Trading report54, where some
of the outcomes reported were:
 Dental patients commonly have insufficient information with which to make
informed decisions about their choice of treatments they receive. It was also
reported that that each year around 500,000 patients may be provided with
inaccurate information by their dentist regarding their entitlement to receive
particular dental treatments on the NHS and, as a result, may pay more to
receive private dental treatment.
The following recommendation was made by the OFT in response to the above
outcome:
 Provision of clear, accurate and timely information for patients - the OFT is
calling on NHS commissioning bodies, the GDC and the Care Quality
Commission (CQC) to be proactive in enforcing existing rules which require
dentists and dental practices to provide timely, clear and accurate information to
patients about prices and available dental treatments.
The CQC, in their first round of inspections of dental practices nationally have majored
on safeguarding and it has been found to be an area where improvements can be made
especially in terms of dental practices knowing the essential points of contact locally for
advice and referral routes to the local authority. Although only 9 dental practices have
been visited by the CQC in NHSS, in an effort to support all dental practices, NHSS and
SCC have devised a guidance document on safeguarding to ensure that all GDPs are
appropriately equipped with the essential information as well as training opportunities
that are available. It would be appropriate to undertake an audit of dental practices in the
near future to ascertain the level of knowledge gained by GDPs in this respect.
It should be noted that the success rate for patients in gaining an NHS dental
appointment in the last 24 months is above national average (as reported in the GP
Patient Survey). The NHS BSA DSD reports also confirm that overall patients are
satisfied with the time they have had to wait for an NHS dental appointment in NHSS,
this being above both regional and national averages. However, patients have not been
totally satisfied with the level of NHS dentistry that they have received once they have
attended for their appointment. This level of satisfaction was above national and regional
averages in Jun 2010 and had fallen to a point where it was below both national and
regional averages in Dec 2011. This satisfaction rate is now level with the national
average, although still below the regional average. Furthermore, 18% of feedback left on
NHS Choices was about dissatisfaction with the level of NHS dental service received.
NHSS monitors all feedback left on NHS Choices and ensures that appropriate action is
taken when a negative comment is received. The issues with respect to patient
satisfaction need to be explored further.
54
Office of Fair trading (2012): Dentistry; available at: http://www.oft.gov.uk/OFTwork/markets-work/dentistry/
Page 73 of 77
Section Eleven
Recommendations
There is an urgent need to develop an Oral Health Strategy for Suffolk in
partnership with all relevant sectors. This will assist all partners in translating the
information into appropriate commissioning intentions for the local population.
The Oral Health Strategy should ensure:
1. A focus on oral health promotion in improving oral health and reducing oral
health inequalities throughout the life-course
There should be an increased emphasis on prevention, especially in children and older
adults in deprived areas where greater levels of inequalities have been identified. The
priority LSOAs have been identified earlier. This could include developing a community
fluoride varnish programme which would need to be overseen by a Consultant or
Specialist in Dental Public Health. Such expert advice and support can be sought from
PHE from April 2013 and the system should ensure that there is adequate capacity to
provide dental public health advice for Suffolk. It should be noted that there is currently
no CDPH covering Suffolk who will transfer over to PHE. Closer partnership working
between all relevant agencies is also required in addressing the wider determinants of
health. Integration of oral health within the broader Public Health and Children’s Services
initiatives following a common risk factor approach e.g. around obesity, breastfeeding
and weaning should also be implemented. It should be ensured that culturally sensitive
messages are imparted. Each community will require a different blend of approaches as
it is unlikely that a single intervention alone will bring about change. There should also
be a commitment to reducing the number of children requiring dental extractions due to
dental decay under general anaesthesia. All oral health promotion interventions should
be evidence based and formally evaluated.
2. Oral health status information
There should be provision to ensure that the dental epidemiology programme continues
to be delivered as currently required by the dental public health directions to PCTs. This
is also one of the PH outcome indicators that will need to be delivered by local
authorities from April 2013. The data from these surveys provide valuable information in
monitoring trends of dental disease in the local population that can be used to inform
commissioning plans.
3. Access to dental services
There should be an assurance exercise undertaken to ensure that the configuration of
NHS dental services is accessible by all groups in society (including vulnerable groups
such as those with learning disabilities and the homeless) for:
 Urgent dental treatment (in-hours and OOH)
 Routine dental treatment (preventive and restorative treatment)
 Dental anxiety management
Access to NHS dentistry also needs to meet the needs of the local population and
therefore patients details of residency (post-code), age and gender should be collated
when receiving in-hours and OOH NHS dental assistance in order for appropriate
analysis on trends to be undertaken. Furthermore, all patients requesting assistance with
Page 74 of 77
sign-posting of available NHS dental services should be further contacted to ensure
success in gaining care. Further investigations are required around access to NHS
dentistry for Children in care. There should also be a clear communication strategy
which includes enhancing the normal communication channels across agencies as well
as involving various media sources.
4. Continuously improving quality
The local dental profession should continue to be engaged in further improving the
quality of dental services that is provided. There should also be appropriate support for
patients and the profession in ensuring that treatment decisions are made in the
patients’ best interest. Patients are entitled to receive all treatment that is clinically
necessary in the opinion of the treating dentist. However, patients’ expectations are
sometimes not necessarily able to be delivered under the NHS. There should be a
mechanism which ensures a clear common understanding of what is available under the
NHS. A pan-Suffolk patient survey would help gain an understanding of patient
expectations and their perceived needs. Engagement with patients and public should
ensure that views are gathered from all sectors of the community particularly BME
communities and those in low socio-economic or deprived areas. Further investigations
are also required in understanding the reasons why NHSS has a higher proportion of
Band 1 and a lower proportion of other bandings of NHS dental treatment. All complaints
and concerns from patients should be analysed after resolution in order to identify trends
in training needs for the local dental profession. LPNs (currently being established)
should ensure clinical involvement in the operational and strategic commissioning
processes undertaken by NHSCB. The core of such networks should comprise a lead
clinician such as a dental public health specialist as well as a dental practice advisor. It
is therefore important to ensure that such expert advice and input is available for Suffolk.
5. Improving efficiency and safety
Improving efficiency through effective management of dental contracts includes using
existing levers to maximise oral health improvement, decrease inefficiencies whilst also
ensuring the delivery of the recommendations in Delivering Better Oral Health which
include fluoride varnish, fissure sealants and sugar-free prescribing. All frontline
healthcare professionals should also be engaged in sugar-free prescribing. Involving the
dental profession in Making Every Contact Count will not only improve the quality of care
being offered to patients but will also improve efficiencies to the system by decreasing
the economic, social and health burdens associated with alcohol abuse and tobacco.
The skill mix within NHS dental services also needs to be considered and adapted over
time to take account of the changing oral health needs of the population. Further
investigations are required to ensure maximum efficiencies of the OOH service
commissioned. Safety of all patients is paramount and appropriate assurance
mechanisms are required to ensure that it is addressed preventatively. A sustainable
provision of care for Head and Neck cancer and trauma cover should be assured.
This OHNA has not covered orthodontics, sedation, minor oral surgery,
domicillary or prison dentistry and therefore further needs assessments will need
to be undertaken to examine these areas in detail. Sections Six to Nine has only
included NHSS and further information is required to understand, map and
analyse the provision of services in Waveney.
Page 75 of 77
Glossary
ACORN
A Classification of Residential Neighbourhoods
ADHS
Adult Dental Health Survey
BASCD
British Association for the Study of Community Dentistry
BME
Black and Minority Ethnic
BSA
Business Services Authority
CCG
Clinical Commissioning Group
COT
Course of Treatment
CQC
Care Quality Commission
DAAT
Drug and Alcohol Action Team
DEP
Dental Epidemiology Programme
DH
Department of Health
DMFT
Decayed, missing or filled teeth (adult/permanent teeth)
dmft
Decayed, missing or filled teeth (baby/deciduous teeth)
DPA
Dental Practice Advisor
DQOF
Dental Quality and Outcomes Framework
DSD
Dental Services Division
EDL
Emergency Dental Line
EY
Early Years
GDC
General Dental Council
GDP
General Dental Practitioner
GDS
General Dental Services
GP
General Practitioner
HMP
Her Majesty’s Prison
HWB
Health and Wellbeing Board
IMCA
Independent Mental Capacity Advocate
IMD
Index of Multiple Deprivation
JSNA
Joint Strategic Needs Assessment
LA
Local Authority
LPN
Local Professional Network
LSOA
Lower-level Super Output Area
NHS
National Health Service
NHSCB
National Health Service Commissioning Board
NHSS
Nation Health Service Suffolk
NMES
Non Milk Extrinsic Sugar
NPSA
National Patient Safety Agency
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NWPHO
North West Public Health Observatory
OFT
Office of Fair Trading
OHE
Oral Health Education
OHNA
Oral Health Needs Assessment
OHP
Oral Health Promotion
OHS
Oral Health Strategy
OMFS
Oral and Maxillofacial Surgery
OOH
Out of Hours
PALS
Patient Advice Liaison Service
PCSDS
Primary Care Salaried Dental Services
PH
Public Health
PCT
Primary Care Trust
PHE
Public Health England
PUFA
Pulpal involvement, Ulceration, Fistula, Abscess
SATS
Suffolk Alcohol Treatment Service
SCC
Suffolk County Council
SHA
Strategic Health Authority
SMT
Serious Medical Treatment
UDA
Unit of Dental Activity
UK
United Kingdom
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