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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 Page 3 of 77 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 Page 4 of 77 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 Page 5 of 77 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 Page 6 of 77 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. Page 7 of 77 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 Page 8 of 77 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 Page 9 of 77 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 Page 10 of 77 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. Page 12 of 77 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 Page 76 of 77 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 Page 77 of 77