Download Oral Health Needs Assessment NHS Norfolk

Oral Dental Health Needs Assessment for NHS Norfolk
Oral Health Needs Assessment
NHS Norfolk
2010 - 2013
Summary
Population, epidemiology and prevention
Everybody needs access to quality dental care and Norfolk’s population is set to increase by
over 10% in the next decade, with relatively larger increases in adult and older age groups
than among children.
There are already higher proportions of older people in Norfolk, particularly North Norfolk
than in England generally and there is a seasonal influx of tourists, who sometimes require
unplanned dental care.
Ethnic groups are in lower proportions than seen elsewhere in the country and there is a risk
that there is a lack of general awareness of specific cultural or language needs or
information services to support these groups.
There is an association between deprivation and poor oral health which is evidenced
repeatedly by local and national survey work.
There are areas of deprivation in parts of Norfolk concentrated mainly in Kings Lynn,
Norwich, Thetford and Great Yarmouth.
Targeted health promotion and drop in styles health services are recommended in areas
where deprivation is most concentrated.
Oral disorders and epidemiology
Most dental diseases are completely preventable, but when they occur they can have life
long effects which require continued professional input.
Investment in oral health promotion and prevention is reasonable as many risk factors for
oral disease are shared with other health conditions and combining health promotion
initiatives is recommended. In Norfolk joint prevention initiatives include Health Trainers,
Change 4 Life, Lets Get Moving and Good 4 You.
Dental health of children has improved enormously in recent years with well over half having
no decay. Higher disease levels are increasingly concentrated among lower income groups
but they may also be seen across the wider population.
Local survey results have continued to show that much dental decay amongst children
remains untreated and there is a variety of reasons for this.
There is evidence that higher socio economic groups are more likely to seek dental
treatment and that people who seek dental treatment only when they have a problem are
more likely to be from a more vulnerable background.
Factors affecting oral disease approaches to prevention
Key risk factors for oral disorders (dental decay, dental erosion, gum disease, oral cancers,
and dental trauma) are poor diet, poor oral hygiene, tobacco and alcohol use and risk of oral
injury. This would as previously suggest there is a place for oral health promotion within
generic health promotion.
Specific evidence based oral health promotion services are beneficial and cost effective if
directed appropriately to particular population groups. Linking oral health to other prevention
services including other health and social care services will also produce a greater effect.
The current dental contract is designed to give dentists enough time to use preventive
techniques and dental health professionals should be encouraged and supported to apply
these.
Oral Dental Health Needs Assessment for NHS Norfolk
The use of water fluoridation at appropriate levels can be protective against dental decay
and is recommended by the Department of Health for high-need populations. But support
with lifestyle choices such as regular brushing with fluoridated toothpaste can also reduce
risk for the individual.
Access to dental services
A useful framework for investment in oral health, set out by Professor Steele in his
independent review of dentistry in 2009, describes a fundamental requirement for urgent
care and pain relief, followed by personalised disease prevention, high quality routine
dentistry, continuing care and lastly, advanced and complex care. This model of care should
be applied across dental provision.
There is a wide variety of oral health services locally but little overview of how they integrate
to provide a population based system. A strategic approach to service planning is
recommended.
The uptake of dental services across Norfolk is currently just below the target of 63% of the
population. NHS Norfolk is commissioning additional activity to improve this performance.
NHS Norfolk is working with providers to ensure that frequency of recall intervals for
checkups is in line with best practice guidance from the National Institute of Health and
Clinical Excellence.
The evidence base upon which dental services in England is published in Delivering Better
Oral Health (DH) and services should be shaped locally to meet need, responding in
particular to the needs of vulnerable patient groups and recognising increasing diversity in
Norfolk’s population. Good information needs to be available on oral healthcare and local
services for all population groups.
Most (83%) dental prevention and treatment takes place through general dental services
with 10% targeted at more vulnerable clients which is provided through salaried providers.
Current primary care contract information
NHS Norfolk has 98 contracts with 82 providers, spread across the county. This delivers
over 1.3 million units of dental activity per year, with a baseline contract value of £32.3M; the
average UDA rate being £23.85. Strategic development has focussed on ensuring access in
major and market towns and their surrounding areas. New providers are building up to full
capacity with further investment planned.
Orthodontic care historically has had long waits to start treatment. Recent investment in
services has taken place and referrals are now centralised through a referral management
service. This enables monitoring and promotion of choice for patients to access services
from a range of providers.
Care for anxious patients depends on specific needs and much of the care locally for adults
is delivered through one large provider. Referral pathways and guidelines are being
developed as part of a review of services for anxious and phobic patients.
Just over one thousand patients were treated on a domiciliary basis in 2009/10 through
general dental services, mainly through a single provider. Provision is currently being
reviewed.
Urgent access to care during normal clinical hours is provided at Kings Lynn and Norwich for
patients who access dental care only when they need it or patients who have problems
accessing their own dentists. Between the two centres, nearly one thousand four hundred
people are seen per month. In addition, other dental practices provide some appointments
and sessions which need to be clearly advertised to patients. There is an out of hours dental
Oral Dental Health Needs Assessment for NHS Norfolk
service, accessed by telephone, for urgent problems, although some patients do try the GP
out of hours service or attend the Accident and Emergency departments.
Special care dentistry is more appropriate for some individuals and most services are based
in Norwich and Kings Lynn, but there are other clinics that operate part time around the
county. Work needs to be done to establish the best pathways for care for patients who
need these services and to promote integrated working between salaried and general dental
services.
The patient voice
Uptake of NHS dental services is relatively high within the Eastern Region and regional
surveys have shown that there have been no significant issues of dissatisfaction with
services in Norfolk in comparison to other areas. However, when judged on access and
flexibility of appointments, the services in Norfolk are ranked below average. This position
may have got worse and NHS Norfolk is planning work to improve this by pro-actively
marketing any future service development.
Main Issues
Link oral health to other prevention initiatives
Develop a strategic approach to service planning for oral health
Drive up quality and support the dental profession to embrace changes
Offer flexible services
Ensure services are efficiently provided
The public, patients and carers need good information about dental health
Please note there is also a separate Executive Summary and Commissioning
Intentions Action Plan Document which is an addendum to this document,
Oral Dental Health Needs Assessment for NHS Norfolk
Introduction, aims and objectives
A healthy mouth is integral to general health and wellbeing, allowing people to eat,
speak, and socialise without active oral disease, discomfort or embarrassment.
Dental decay and gum disease remain widespread across the population, costly to
treat but preventable. Hence they are public health issues.
Since the introduction of fluoridated toothpaste in the 1970s, there have been large
reductions in tooth decay but not everybody benefits equally. Population averages
mask oral health inequalities and oral disease levels reflect gender, age, ethnicity,
geographic location and socio-economic group and there is strong evidence that
dental disease is increasingly concentrated among socially disadvantaged groups.
Most people use dental services and Primary Care Trusts are required by the
Department of Health to have a strategic approach to planning as set out in
Improving dental access, quality and oral health (2009), and a statutory duty to
provide oral health services to meet local needs. Standards are set out in Choosing
Better Oral Health – an Oral Health Plan for England (2005) and supported and
further developed by later publications such as ‘Delivering Better Oral Health (2007)’
with further recommendations made in The (independent) Steele Report (2009).
Regional priorities are described in terms of twelve pledges (Towards the best
Together 2006). Two of these East of England Pledges apply specifically to
dentistry: pledge 4 ‘We will ensure that NHS Primary dental services are available
locally to all who need them’ and pledge 2 ‘We will extend access guarantees to
more of our services’, where it was agreed that primary care based orthodontic
services would be one of these services. Further, Pledge 9 states that ‘we will
ensure healthcare is as available to marginalised groups and looked after children as
it is to the rest of us’.
Dentistry is explicit in the Joint Strategic Needs Assessment Plan for NHS Norfolk,
Bold and Ambitious (2009) and significant commissioning has already taken place,
informed by a series of local needs assessments through the JSNA , overseen by the
PCT Board (December 2009). It is now timely to revisit our local needs assessment,
identify successes, good practice, inefficiencies and gaps to inform commissioning
decisions for the PCT Operating Plan 2010 and for the years beyond.
Dental commissioners at NHS Norfolk are committed to this refreshed needs
assessment for use as the organisational changes, described in the White Paper,
Liberating the NHS, take place. Changes include the abolition of PCTs and the
establishment of a National Commissioning Board and Public Health Service, with
the Local Authority taking the strategic lead locally, supported by a public health
team. Dental services will be commissioned through the National Commissioning
Board. The dental contract (for General Dental Services) will be replaced, but only
after a pilot, by a successor contract to be published in December 2010, when the
White Paper on Public Health is also expected.
Recommendations from this needs assessment will reflect core values of NHS
Norfolk, including respect for diversity within the population and the need for equity
across the whole population, taking account of the recent independent review on
health inequalities. NHS Norfolk acknowledge: The Marmot Review (2010).
NHS Norfolk acknowledge Jennifer Donaghy, specialist trainee in Dental Public
Health, who produced the original literature reviews, which we updated and adapted
to be relevant to Norfolk in 2010
Oral Dental Health Needs Assessment for NHS Norfolk
Aims
To undertake a dental health needs assessment for Norfolk, establishing a shared
understanding of
•
•
•
•
dental health
the roles, current provision and costs of publically funded dental services
views of the public, patients and professionals
evidence upon which prioritising for future investment, disinvestment and
development can be done.
Objectives
1. To understand the demographics of Norfolk
2. To describe key oral diseases and disorders and their impact across the whole
population
3. To understand what can be done to prevent oral disease
4. To describe current service provision, pathways into care, costs and outcomes
5. To review feedback received through PALs and complaints
6. To consult with the dental profession through the Local Dental Committee and
the Oral Health Advisory Group
7. To make supported, evidence based and costed recommendations to NHS
Norfolk on priorities for investment and for saving.
Oral Dental Health Needs Assessment for NHS Norfolk
Processes and data sources
Process:
The process of this exercise is shown diagrammatically below:
Demographics,
epidemiology and
prevention
(Lead: Public Health)
Professional overview,
actual and potential patient
pathways, quality and
professional issues (Lead:
Oral Health Advisory Group)
NHS Services, budgets,
costs, quality, capacity and
pressures
(Lead: Contracting Team)
Describing met and
unmet need (Gap
analysis) and defining
priorities
(Lead: Dental Needs
Assessment Team)
Draft evidence based document for
consultation with
PEX/LDC/OHAG/PCT/Local Authorities
Commissioning activity and monitoring
Delivery of PCT
statutory functions:
population screening,
surveys and prevention
programmes
Better geographical spread of
primary care services, meeting
current quality standards and more
information about them.
Clearer pathways to,
and appropriate use
of, specialised
services
Increased capacity to see
and treat irregular attendees
and to address inequality of
access
Oral Dental Health Needs Assessment for NHS Norfolk
Overview of key data and reference sources:
Demographics, epidemiology
Nationally published ONS population data
ONS National dental surveys
Local dental surveys, coordinated nationally (BASCD surveys)
The English NHS Dental Epidemiology Programme
Local information from the Norfolk Joint Strategic Needs Assessment (JSNA)
Prevention of dental disease
Choosing Better Oral Health. An Oral Health Plan for England (Gateway 4790)
(Department of Health 2005)
Statutory Instrument (2006)
Delivering Better Oral Health (Department of Health 2007)
Primary care and community services: improving dental access, quality and oral
health (Department of Health 2009, (Gateway 11000)
Pathways and quality
NICE guidance on extraction of Wisdom Teeth and on Recall interval
Project work with the Norfolk Oral Health Advisory Group (2009 and 2010)
Improving dental access, quality and oral Health (World Class Commissioning)
Building Relationships: dental contract management handbook (Primary Care
Commissioning) 2010
Improving oral health and dental outcomes: developing the dental public health
workforce in England (March 2010)
NHS dental services in England: an independent review led by Professor Jimmy
Steele, 2009.
Local primary and secondary care service information
Contract information from e Reporting
Contract monitoring of salaried dental services
Secondary care information from the HES database
Local Audit of referral management centre data
Local Audit of sedation services
Local Audit of calls to A&E and out of hours GP services
Local Audit of PALs enquiries and complaints of the past 12 months.
Outline document design and baseline literature review
Oral Health Needs Assessment, NHS Hertfordshire 2008.
Oral Dental Health Needs Assessment for NHS Norfolk
Contents
Part 1:
Section 1:
Population, epidemiology and prevention
Population and Demography of Norfolk
1.1
1.2
1.3
Demography and trends
Ethnicity
Deprivation in Norfolk
Summary points
Section 2:
Common Oral Disorders and epidemiology
2.1
The disorders
• dental decay (caries)
• gum (periodontal) disease,
• oral cancer
• malocclusion and orthodontics
Oral Health and inequalities in Children
• Dental Caries
• Cleft Lip and Palate
• Orthodontic Treatment Need
Oral Health and inequalities in Adults
• Dental Caries
• Gum (Periodontal) Disease
• Oral Cancer in Adults
Summary points
2.2
2.3
Section 3:
Factors affecting oral disease and approaches
to prevention
3.1
3.2
Biological and Social Determinants
Using the Common Risk Factor Approach to tackle inequality
• Diet
• Overweight and Obesity
• Smoking
• Alcohol misuse
• Drug misuse
Populations in special situations
Summary points
3.3
Section 4:
Prevention Services
4.1
4.2
4.3
4.4
Water Fluoridation
School dental inspections
Dental Check ups
Oral Health Promotion
Summary points
Part 2
Dental Care Pathways, services in Norfolk, gaps,
efficiencies and productivity
Dental Care Pathways
Section 5:
5.1
5.2
5.3
Overview of system
Current Pathways for dental care in Norfolk
Overall spend
Summary points
Section 6:
Current primary care contract information
6.1
6.2
General dental services
Current contracts location of services, activity and feedback through
PALS
Local Orthodontic service provision – current contracts, activity,
referrals
6.3
7
Oral Dental Health Needs Assessment for NHS Norfolk
Contents
6.4
6.5
6.6
6.7
Local Sedation services provision – current contracts
Local Domiciliary services provision – current contracts
Local Access services provision – current contracts
Local Special care services provision – current contracts
Summary points
Section 7:
Secondary care and referral management
7.1
7.2
7.3
Hospital out patients
Daycases, emergency and elective
Referral management
Summary points
Section 8:
Public Voice
8.1
8.2
8.3
8.4
National Surveys
Regional Surveys
Local Surveys
Reports from PALs and complaints
Summary points
Figures & Tables
References
Section 9:
8
Oral Dental Health Needs Assessment for NHS Norfolk
Part One: Population, epidemiology and prevention
Section 1: Population and Demography of Norfolk
Norfolk overview
Most people use dental services. NHS Norfolk had a population projection of 766 900
for mid 2010, increasing by around 10% over the next decade.
General public health issues that relate to oral health are smoking and obesity.
Smoking prevalence rate is 19.4%, lower than the England average and has reduced
in recent years. There still remains, however, 117 591 smokers. 1 in 5 adults are
obese and the number of diabetics is increasing. A role for all dental services is to
provide smoking cessation advice and dietary advice.
On average, men and women in NHS Norfolk live longer than the average in
England. Rates of early death from heart disease, stroke and cancer have fallen
over the last decade and are lower than the England average. Estimated deaths
from smoking in Norfolk are 1400 per year, a rate of 172.2 per 100 000, a good deal
lower than the rate of 206.8/100 000 across England. Across the Anglia Cancer
Network there are just over 400 new cases of oral cancer registered per year.
Older people today are likely to have complex dental care needs due to disease and
treatment patterns earlier in their lives. Younger populations have different care
needs, often with less experience of dental decay but the need for long-term
maintenance of a healthy mouth.
1.1 Demography and trends
Figure 1 illustrates population increases that have already taken place in NHS
Norfolk between 2002 (the bars) and mid 2008 (the lines) and hence potentially put
pressure on existing dental services. Data on this six year time interval show that by
the end of this period there were, for example, nearly 13 000 extra people aged 65
and over, of whom 5 700 were aged 80 and above.
9
Oral Dental Health Needs Assessment for NHS Norfolk
Figure 1 Recent population increases in Norfolk (Mid 2002-2008, ONS)
Total estimated resident population by age and sex, NHS Norfolk population growth, mid-2002 compared mid
2008 population
-30000
-20000
-10000
0
10000
20000
30000
0
85+
80-84
2
75-79
70-74
4
65-69
Age (5 year bands)
60-64
6
55-59
50-54
8
45-49
40-44
10
35-39
30-34
12
25-29
20-24
14
15-19
10-14
16
5-9
0-4
18
30000
20000
10000
0
2002 Females
Population
2002 Males
10000
2008 Females
20000
30000
2008 Males
Population projections over the next decade in Norfolk, shown in Figure 2, anticipate
further increases of over 10% across all age groups, with greatest increases among
30 - 34 year olds and 70 - 74 year olds, and with those in their fifties not far behind.
This is relevant in that people under forty are more likely to have dental health and a
low treatment need, whereas older people today are likely to have past treatment for
dental disease that requires maintenance. Very few people today are edentulous
(i.e. with all teeth having been extracted in the past).
Figure 2: Population projections for Norfolk: 2010 and 2020 (source: ONS)
Changes in Norfolk population between 2010 and 2020
70000
70000
2020
60000
60000
50000
50000
40000
40000
30000
30000
20000
20000
10000
10000
10
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0
5-9
0
0-4
Number of persons
2010
Oral Dental Health Needs Assessment for NHS Norfolk
Looking specifically at children, Norfolk in 2010 has approximately 181, 500 19 year
olds. The largest rise within this age group over the next ten years is among 5 to 9
year olds, from 41,828 to 52,793 (an extra 10,985, an 18% rise) by 2020. This will
be partially offset by a drop of about 7% of 15 – 19 year olds, currently estimated at
nearly 50 000 to 46 640.
The recent Children’s Dental Health Survey in 2003 found that 35% of 12-year-olds
in England would benefit from orthodontic treatment.i This figure is often used to plan
commissioning of orthodontic services, with the caveat that not all of these children
will seek, accept or be suitable for orthodontic treatment. In Norfolk there are
approximately 9,330 12 year olds and this number has reduced in recent years and is
projected to reduce further over the next few years. This is revisited in the last part of
Section 2.2 on orthodontic treatment need.
The graphs below (Figure 3) show the distribution of the young population by age
band by district in 2008. Location of services should anticipate this distribution,
alongside the distribution of the oldest members of society, illustrated next, as both
groups will have a proportion unlikely to travel far for routine care, whereas working
age adults often commute to a town or city for employment and recently retired
people for leisure and other services and may prefer to access their care there.
11
Oral Dental Health Needs Assessment for NHS Norfolk
Figure 3: males and females 0 – 19 by District in Norfolk (ONS data, 2008)
Number of Males aged 0-19 by age band, gender, and district for Norfolk, 2008 (source: ONS)
18,000
16,000
14,000
12,000
10,000
15-19
10-14
8,000
5-9
0-4
6,000
4,000
2,000
0
Breckland
Broadland
Great Yarmouth King's Lynn and
West Norfolk
North Norfolk
Norwich
South Norfolk
Number of Females aged 0-19 by age band, gender, and district for Norfolk, 2008 (source:
ONS)
18,000
16,000
14,000
12,000
10,000
15-19
10-14
8,000
5-9
0-4
6,000
4,000
2,000
0
Breckland
Broadland
Great Yarmouth
King's Lynn and
West Norfolk
North Norfolk
Norwich
South Norfolk
It is particularly important that across all districts services are proportionate for all age
groups.
Figures 4 and 5 compare proportions (ONS mid year projections for 2010) of people
aged sixty five and over and eighty and over respectively in the districts within
Norfolk and with the Norfolk and England averages. For both age groups, the
proportions are largest in North Norfolk, where those aged 65+ approach 30% (the
largest proportion in the country) with over 8% aged eighty or over. For all districts
12
Oral Dental Health Needs Assessment for NHS Norfolk
except Norwich, the proportion is over 5% more than the England average (65+) and
over 1% more (80+).
Figure 4: Proportion of Population 65+
Proportion of the population aged 65+ (by District) ONS 2010 projections
30.0%
% population
25.0%
20.0%
% 65+
Norfolk 65+
England 65+
15.0%
10.0%
5.0%
0.0%
Breckland
Broadland
Great
Yarmouth
King's Lynn
and West
Norfolk
North
Norfolk
Norwich
South
Norfolk
Figure 5: Proportion of Population 80+
Proportion of the population aged 80+ (by District) ONS 2010 projections
9.0%
8.0%
% population
7.0%
6.0%
% 80+
Norfolk 80+
England 80+
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Breckland
Broadland
Great
Yarmouth
King's Lynn North Norfolk
and West
Norfolk
Norwich
South
Norfolk
Figure 6 maps the proportions of people aged sixty five and over. These age groups
frequently live in rural and remote areas of Norfolk although some live in urban areas.
13
Oral Dental Health Needs Assessment for NHS Norfolk
Figure 6: Map showing Proportion of Population 65+ in Norfolk
Seasonal population increases
Norfolk has a thriving tourist industry which brings in temporary residents, particularly
in the summer months. The implication for dental services is that these people might
need urgent care whilst away from their regular services
The compendium of tourism statistics identifies the following numbers of tourists
visiting Norfolk in the years 2005 – 2008:
Table 1: numbers of tourists to Norfolk and nights stayed.
(Source: Tourist office)
Year
2005
2006
2007
2008
Norfolk staying trips (i.e.
not day trips) (millions)
4.597
4.447
4.220
3.979
Norfolk: nights stayed
16 816
16 963
15.841
15.081
1.2 Ethnicity
The specific needs of many minority groups are increasingly being identified.
England has a much higher ethnic diversity than Norfolk. Ethnic groups in Norfolk
have a much lower profile than in other areas and hence there is an increased risk
that their needs can be overlooked. Data is insufficiently accurate to map the
distribution of this small and diverse population that includes academics, employed
and self employed, migrant workers, and travelling families.
14
Oral Dental Health Needs Assessment for NHS Norfolk
Figure 7a: Estimated Ethnic composition of England, 2007 mid year estimate
(ONS Experimental Statistics)
Mixed
2%
Asian
6%
Black
3%
Chinese or other
1%
White Other
3%
White Irish
1%
White British
84%
Figure 7b: Estimated Ethnic composition of NHS Norfolk (residents), 2007 mid
year estimate (ONS Experimental Statistics)
Mixed
1%
White Irish
1%
Asian
1%
White Other
3%
Black
1%
Chinese or other
1%
White British
92%
In NHS Norfolk, the proportion of ethnic groups has changed significantly since the
Census in 2001. The results from the 2001 Census showed NHS Norfolk to have a
majority White British population (98.47%) and a very small minority of people of a
non-white British population (1.53%). Since 2001, the non-white British population
15
Oral Dental Health Needs Assessment for NHS Norfolk
had been estimated to have doubled in NHS Norfolk to approximately 3.1% of the
general population. NHS Norfolk has also experienced a net gain in the number of
migrant workers coming from Europe to work and live since the 2001 Census. The
settlers from Poland, Lithuania, Portugal, and Latvia often have complex needs in
terms of accessing healthcare services relating to cultural differences and
communication. The health needs of these groups have not been well investigated.
1.3 Deprivation in Norfolk
Deprivation is an important consideration when assessing needs for local dental
services. It has been shown to be strongly associated with dental ill-health; for
example children living in more deprived areas experience more dental decay (Tickle
et al., 2000). This is explored in more detail in Section 2 on oral disease. It must also
be appreciated that there may be differences in interest and priority for routine dental
care for people with more deprived circumstances and they may need different
approaches to tackling their problems.
The Index of Multiple Deprivation (IMD) 2007 provides a summary measure of
deprivation for each of 32 482 small geographical areas in England, called ‘lower
super output areas’ (LSOAs). Each area has around 1,500 people and data can be
combined to provide scores for larger areas such as current electoral wards. There
are 3,550 LSOAs in the East of England, 530 in Norfolk and 469 in NHS Norfolk. The
reader is referred to the following website for more information:
http://www.communities.gov.uk/documents/communities/pdf/576659.pdf
Essentially, for each small geographical population group, deprivation is scored
across seven domains, containing a number of indicators which are weighted and
combined. The domains and weights are shown in Table 2, with emphasis on
money, health and education.
Scores are combined to middle layer super output level across Norfolk as shown in
Figure 8, where the map shows deprivation to be concentrated in Kings Lynn,
Norwich, Thetford and Great Yarmouth areas, with wider areas around the coastal
areas particularly in the North and West. Conversely, least deprivation surrounds
Norfolk, across Broadland and areas of Southern Norfolk and Breckland.
Table 2: Domains of multiple deprivation and their weights
Domain name
Income deprivation*
Employment deprivation
Health deprivation and disability
Education, training and skills deprivation
Barriers to housing and services
Living environment deprivation
Crime
* There
•
•
are two supplementary indices:
Income deprivation affecting children
Income deprivation affecting older people
16
Weight used in
index
22.5
22.5
13.5
13.5
9.3
9.3
9.3
Oral Dental Health Needs Assessment for NHS Norfolk
Figure 8: Deprivation in Norfolk
Comparing deprivation: quintiles
Nationally, LSOA areas have been ranked 1 – 32,482 according to IMD score; 1
represents the most deprived. The list has then been divided into five ‘quintiles’ of
6496, the top quintile (1) being the 20% most deprived and the bottom (5) being the
20% least deprived. Figure 9 shows the distribution in Norfolk and NHS Norfolk of
our LSOAs according to national quintile; across the Nation, all the bars would be of
equal length. Locally, we see the commonest quintiles to be average (3) or above (4
or 5).
Figure 9: Number of LSOAs for Norfolk and NHS Norfolk in each national
deprivation quintile
180
166
160
149
136
140
126
Number
120
100
89
83
80
72
56
60
40
83
39
20
0
1 (Most deprived)
2
3
National deprivation quintile (IMD 2007)
17
4
5 (least deprived)
NHS Norfolk
Norfolk
Oral Dental Health Needs Assessment for NHS Norfolk
Norfolk has 56, and NHS Norfolk, 39 LSOAs in the most deprived 20% (quintile) of
6,496 LSOAs (1). The national picture for this quintile is that just over a third of the
people are income deprived, one in five of women aged 18-59 and men aged 18-64
are employment deprived and just under half of children live in families that are
income deprived and nearly 40% of older people income deprived. It is to be noted,
however, that most of these 6,496 LSOAs in the lowest quintile nationally are in the
North East and North West of England; our local areas number among only 223
found in the East of England and so their collective characteristics may be different.
Health promotion initiatives are already targeted in these most deprived areas, and it
is recommended that dental issues should be dealt with alongside. Additionally there
should be easy access to ‘drop in’ style dental services for more deprived areas.
Eighty three of Norfolk’s LSOAs fall into the least deprived quintile (5) (again 6496
LSOAs nationally). These 83 are all within the boundary of NHS Norfolk. The
numbers of LSOAs within the worst and least deprived national quintiles are
summarised in Table 3 and are important to inform our consideration of health
inequality within districts.
Table 3: Worst and least deprivation by district (measured by IMD 2007)
District
Great Yarmouth
Norwich
Kings Lynn and W Norfolk
North Norfolk
Breckland
South Norfolk
Broadland
Norfolk
Number LSOAs in
most deprived 20%
(6496)LSOAs
nationally
17
28
9
1
1
0
0
56
Number LSOAs in
least deprived 20%
(6496) LSOAs
nationally
0
8
9
2
9
24
31
83
Despite this ranking of very small areas, there is no standard comparison or
description of larger areas such as local authorities, other than ranking, because of
the range of indicators that contribute. Overall rankings for the seven districts of
Norfolk out of the 354 in England are shown in Table 4, with Norfolk itself ranking 97
out of 149 counties, i.e. almost within the top third, hence well below average overall
deprivation. It would appear that a good range of standard NHS dental services
would be a wise approach to catering for this majority.
Table 4: IMD score and rank of Norfolk districts within 354 in England
(1 = most deprived)
District
Rank of average score
Great Yarmouth
Norwich
Kings Lynn and W Norfolk
North Norfolk
Breckland
South Norfolk
Broadland
58
62
137
160
213
286
301
18
Oral Dental Health Needs Assessment for NHS Norfolk
Exploring inequality in further detail, LSOAs in each district can be categorised by the
national quintile into which they fall such that the distribution can be seen and
compared (Figure 10).
Figure 10: Number of LSOAs in each national quintile by district
Number of LSOA by national deprivation quintile for each district in Norfolk (IMD 2007)
40
40
35
1 (Most deprived)
2
3
4
5 (least deprived)
33
32
31
31
30
28
25
Number
32
24
23
22
20
20
20
18
17 17 17
15
16
13
15
13
10
9
10
9
10
9
8
6
5
1
0 0
1
0
3
2
0
0
Breckland
Broadland
Great Yarmouth
King's Lynn and
West Norfolk
North Norfolk
Norwich
South Norfolk
District
Broadland is the least deprived area overall, and Norwich the most deprived. Within
each area, however is a wide range of circumstances of residents and service
planners and providers should be mindful of this and cater for a range of needs.
Mental Wellbeing
Wellbeing is related to overall health (section 3). There is now a child wellbeing
index, along the lines of the IMD index. Scores for 2009, for the seven Norfolk
districts among 354 English districts are shown in Table 5, where 1 is maximum
wellbeing.
Table 5 Index for child wellbeing (2009)
Source: Public Health,, NHS N
Area
Child Wellbeing
index
Broadland
South Norfolk
Breckland
North Norfolk
Kings Lynn and W Norfolk
76.68
83.22
124.05
127.87
161.58
Rank within 354 districts
nationally* (1 is maximum
wellbeing)
47
67
170
179
238
Great Yarmouth
Norwich
Norfolk*
191.74
236.45
141.54
289
329
58*
*Norfolk ranks 58 out of 149 counties nationwide.
19
Oral Dental Health Needs Assessment for NHS Norfolk
The seven domains that contribute to the scores are material well-being, health,
education, crime, housing, environment and children in need. Children in Norwich,
collectively, have a much lower experience of wellbeing than in most other parts of
the county according to this index.
This has not been directly related to oral health, but will contribute generally to the
social determinants of health dealt with in more detail in Section 3.
20
Oral Dental Health Needs Assessment for NHS Norfolk
Summary points Section 1
Demographics and dental care needs
•
Everyone needs access to dentistry. There is currently a population of 766,900 people in
NHS Norfolk, increasing by over 10% over the next decade with largest increases among
30 to 34 and 70 to 74 year olds.
•
Anticipated increases in the numbers of children are relatively lower than for the rest of
the population (increase of 8%) and the number of 12 year olds, the age where
orthodontic treatment is usually planned, will fall slightly, indicating that current services, if
adequate now, will have capacity to meet needs for the foreseeable future.
•
All districts bar Norwich have higher proportions of older people than England or Regional
averages, North Norfolk particularly so. It is important to recognise this while
commissioning for the whole age spectrum.
•
There is an important tourism industry that brings in people who may have urgent dental
care needs, particularly in summer months.
Ethnicity and dental care needs
•
Ethnic groups make up a much smaller (hence at greater risk of being overlooked)
proportion of the population in Norfolk, compared to England. The proportion is
increasing. Enabling access to dental care across the wide range of circumstances for
ethnic groups (for example, migrant workers and their families compared to families who
have lived in Britain for many years) will require a proactive approach from providers
(some of whom are, themselves migrant workers) that includes better understanding of
the use of translating/interpreting services and tailored approaches where other specific
barriers are identified.
Deprivation and dental care needs
•
There is an association between deprivation and poor oral health, evidenced repeatedly
by local and national survey work.
•
The index of multiple deprivation provides an objective measure for geographical areas
with a population as small as 1, 500 people; these can be ranked but scores do not
necessarily provide a blanket description to cover issues specific to any individual
community and within each local area these are individuals and families with varying
circumstances.
•
Mapping deprivation by this index highlights concentration in Kings Lynn, Norwich,
Thetford and Great Yarmouth. Conversely, least deprivation surrounds Norwich,
covering Broadland and areas of Southern Norfolk and Breckland.
•
Many areas fall into the median quintile of deprivation when compared nationally, and
overall the county tends towards relative affluence and not deprivation.
•
Targeted health promotion and drop in style health services are recommended where
deprivation is most concentrated. Across all other areas a standard range of NHS dental
services is recommended that are flexible to meet varying need, particularly the
demographics outlined earlier, and also for vulnerable groups, described in Section 3.
21
Oral Dental Health Needs Assessment for NHS Norfolk
Section 2: Common Oral Disorders and epidemiology
2.1
The disorders
Dental Decay (Caries)
Dental decay is completely preventable but one of the most common chronic
diseases. It occurs when tooth tissue is demineralised by the acids formed by dental
plaque in response to dietary sugars and is treated by professional removal of the
damaged dental tissue and restoration of the tooth (filling, endodontic treatment and
possibly fitting a crown to restore function), or else removing the whole tooth
(extraction) and replacing with a bridge or denture.
Evidence has consistently shown that sugars are the most important factor in caries
development.ii ‘Free sugars’ include all monosaccharides and disaccharides as well
as those naturally present in honey, fruit juices and syrups.ii1 and these can cause
the harm. The annual consumption of free sugars has increased since the 1970s.iii
The sugars naturally present in whole fruits, vegetables and milk are thought not to
be harmful to dental or general health.
Evidence on prevention of dental disease is presented in Choosing Better Oral
Health (Department of Health, 2005), delivered through the ‘common risk factor’
approach, described below.
Gum (Periodontal) Disease
Gum or periodontal disease is preventable, caused by inflammation of the gums and
bone that support and anchor teeth. When severe, the bony support for teeth is
extensively compromised causing otherwise healthy teeth to be lost. The cause of
this disease is poor plaque control (tooth brushing technique), exacerbated by
smoking, certain systematic diseases (such as Diabetes), genetic factors and stress.
There is an association with social deprivation and prevalence increases with age.
There are a number of gum (or periodontal) diseases; however the disease with
public health implications is chronic periodontitis in adults. Chronic periodontitis can
cause bleeding gums, loss of periodontal attachment, recession of gums, periodontal
abscesses, drifting of teeth, tooth mobility and ultimately tooth loss. These
symptoms can have a significant impact on the individual ranging from halitosis and
discomfort to changes in appearance and loss of function.iv
Evidence on prevention of periodontal disease is found in Choosing Better Oral
Health (Department of Health, 2005), delivered through the ‘common risk factor’
approach, described below.
Oral Cancer
Oral cancer is a generic term that is used to describe all malignancies of the oral
cavity, oropharynx and hypopharynx (such as squamous cell carcinoma of the lip and
tongue).
Almost all oral cancers are thought to be preventable. An estimated 80% are caused
by tobacco (smoking or chewing), alcohol or a combination of the two. Although
tobacco and alcohol are independent risk factors, their combined effect is greater
than the sum of the risks from exposure to either on its own.v An estimated 10–15%
of oral cancers may be caused by unhealthy diets.vi There have been about 414 new
cases per year across the Anglia Cancer Network that includes Norfolk, Suffolk and
Cambridge.
Oral cancers are more prevalent amongst deprived populations and often they
present late into the healthcare system, demanding more radical treatment and
22
Oral Dental Health Needs Assessment for NHS Norfolk
shortening life expectancy. Prevention and earlier detection are aims to strive for,
using the common risk factor approach, described in Section 3.
Malocclusion and Orthodontics
Malocclusion is not a disease but the collective term given to natural variations from
the ‘ideal’ in the relationships of the teeth and jaws. Its presence is not synonymous
with a need for treatment.vii There is a lack of evidence to suggest that
malocclusions have a detrimental effect on oral health, although by affecting facial
appearance malocclusions can have an impact on psychological well-being and
quality of life.viii Because malocclusion is not a disease and orthodontic treatment
carries risks (e.g. root resorption, decalcification and non-improvement)xvi it is
particularly important to evaluate the risk-benefit balance of any possible treatment.
In the UK, need for orthodontic treatment in the NHS is assessed using the ‘Index of
Orthodontic Need’ (IOTN). The IOTN incorporates both an aesthetic and dental
health component. Both of these aspects of a malocclusion are clinically assessed to
determine whether a patient is likely to benefit from treatment. The clinician assigns
a dental health component grade of treatment need between 1 and 5 (with 5
representing greatest need) and an aesthetic component grade of treatment need
between 1 and 10. Under the current regulations, a patient is entitled to NHS
orthodontics if their malocclusion has been graded as follows:ix.
•
Grade 4 or 5 of the Dental Health Component of the Index of Orthodontic
Treatment Need.
•
Grade 3 of the Dental Health Component of that Index with an Aesthetic
Component of 6 or above.
Nationally about 35% children aged 12 have an IOTN of 3.6 or above. NHS Norfolk
has a policy with acute providers that consultant lead hospital care treats only the
dental health component 4 and 5.
2.2 Oral health and inequalities in children
The dental health of children has improved enormously since the 1970s; however,
population averages mask oral health inequalities. A well-recognised association
exists between socio-economic status and oral health, and trends suggest that
disease is increasingly concentrated in the lower income groups.
Dental caries
In the UK data on dental caries is regularly collected to allow trends in dental disease
to be monitored. Key surveys that provide information on trends in oral disease at a
national level are the decennial Children’s Dental Health Survey and the British
Association for the Study of Community Dentistry (BASCD) surveys of children’s
teeth. The latter are analysed at a local level and are now run by the NHS through
the North West Public Health Observatory.
Local contribution to survey work is a Statutory Function of a PCT and therefore must
be commissioned. The expertise usually lies within the salaried dental service hence
they are the usual provider.
Dental caries is commonly measured using the dmft index, which is a record of the
number of decayed, missing and filled teeth (dmft). By convention, upper case dmft
is used to denote permanent teeth (DMFT) while lower case dmft is used to denote
primary teeth.
The prevalence of dental caries in children has decreased substantially over the past
40 years (Figure 4.1.1). The greatest improvement in the decay experience of five23
Oral Dental Health Needs Assessment for NHS Norfolk
year-olds was seen between 1973 and 1983, during which time the mean number of
decayed, missing and filled teeth (dmft) per child halved and the percentage of
children without any caries (caries free) doubled.
Figure 11:
Reduction in dental decay amongst children in UK, 1979 – 2009.
Source: National Children’s Dental Health Surveys 1973 to 2003. Harker R and Morris J
(2005). Office for National Statistics, London. In Choosing Better Oral Health, Department of
Health (2005): http://www.dh.gov.uk/assetRoot/04/12/32/53/04123253.pdf
The graph indicates the last decade to have resulted in little further reduction in
dental decay. There continues to be a burden of disease in small children, which is
difficult to address; a small proportion of the population experiences a high proportion
of the disease and children who have decayed teeth will have, on average, between
3 and 4 decayed teeth therefore most of the population’s decay. The same pattern
is found at both regional and national levels. Dental caries, like many other diseases,
is increasingly associated with social deprivation.x Children from socially
disadvantaged groups experience disproportionately high levels of dental disease.xi
The 2003 National Children’s Dental Health Survey found (Figure 12) that children
from manual classes are more likely to experience caries than those from nonmanual classes.xii
Figure 12:
Mean Number of Teeth with Obvious Decay Experience by SocioEconomic Status of Household in the UK 2003*
3
2 .5
M a n a g e ria l a n d
P r o fe s s i o n a l
2
In t e r m e d i a t e
1 .5
R o u t in e a n d M a n u a l
1
0 .5
0
5 year
o ld s
8 year
o ld s
12 year
o ld s
15 year
o ld s
Source (Figure 12): Office for National Statistics. 2003 Children’s Dental Health Survey.
London: ONS; 2004. Available at URL www.statistics.gov.uk/children/dentalhealth
*Hashed columns indicate primary teeth, solid columns indicate permanent teeth
24
Oral Dental Health Needs Assessment for NHS Norfolk
Similarly, there is a correlation between the percentage of children with decay
experience and deprivation; deprived groups are more likely to have decay
experience. This pattern is seen in both the primary and secondary teeth.
Locally the dental health of children in Norfolk varies around the national and regional
averages as shown by the local data, regularly collected through British Association
for the Study of Community Dentistry (BASCD) co-ordinated surveys. In the sample
of five year olds surveyed during 2007-2008, there was a requirement for explicit,
positive consent from parents/carers of children before they could participate. Of
note, for the samples drawn, less than 70% took part. Of the participants, around
27% of those in Norfolk had experience of dental decay; conversely 73% (nearly
three quarters) were decay free. This compares favourably with national levels, as
shown in Table 6. It would be expected that those not participating in the survey
might have higher rates of decay and less engagement with services and so the
survey results are probably an underestimate of the true picture, particularly
underestimating those with higher need.
Table 6 Dental survey results National comparison: five year olds 2007 – 2008.
Area
England
East of England
Norfolk
5 year old
population
mid 2007
558,566
62,935
7,023
Sample
drawn
%
examined
% decay
free
Care
index*
209,152
17,142
1,758
66.8
69.3
60.9
69.9
75.2
73.2
14
19
10
Where dental decay was evident, a greater proportion was untreated than seen
either regionally or nationally (*the Care Index is the proportion of teeth with caries
experience which have been filled, derived by taking the number of filled teeth and
dividing by the total number of decayed, missing and filled teeth). There is
disagreement within the profession regarding appropriateness and benefit of filling
decayed deciduous teeth and a lack of evidence based guidance on this. The
highest index in the country was 33% in South Gloucestershire.
25
Oral Dental Health Needs Assessment for NHS Norfolk
Table 7 Local data on 5 year olds in Norfolk 2007 – 8
The data in table 7 are further broken down to compare local authority areas in
Norfolk. Breckland, Broadland and North Norfolk all had a care index of below 10.
It can be expected that those not decay free will have high rates of disease.
England
East of England
Breckland
Broadland
Kings Lynn and
West Norfolk
North Norfolk
Norwich
South Norfolk
5 year old
population
mid 2007
558,566
62,935
1,271
1,237
1,459
Sample
drawn
%
examined
% decay
free
Care
index*
209,152
17,142
293
317
299
66.8
69.3
56.0
68.5
57.5
69.9
75.2
83.9
73.9
83.6
14
19
7
8
14
811
1 055
1 190
289
294
266
60.6
55.1
67.7
62
65.8
71.7
8
11
10
National performance targets for dental health in young children stated that by 2003,
an average of 70% of children should have no experience of dental decay. This
target was met across the East of England and Norfolk, but not England as a whole
according to this survey which took place some years after 2003 but had a low
participation rate.
The pattern of oral health inequalities seen at a national level is repeated locally.
PCT or district averages hide oral health inequalities and the fact that a small
proportion of the population experiences a high proportion of dental disease. The
dental health inequalities mirror social deprivation.
Local co-ordinated dental surveys are now run as the English NHS Dental
Epidemiology Programme and the results of the 2008/9 survey of twelve year olds
are shown below. Over a third of children have some dental decay that needs
professional intervention (D3MFT) but a small proportion of this need is actually met,
particularly in Great Yarmouth and North Norfolk (the care index). No data are
shown for Kings Lynn and West Norfolk or for Breckland because the numbers
sampled were too small.
26
Oral Dental Health Needs Assessment for NHS Norfolk
Table 8 - The Decay Experience of 12-year-old Children in Norfolk (The
English NHS Dental Epidemiology Programme Survey of 12 year olds,
2008/9)
PCT Name
England
Norfolk
Broadland
Great
Yarmouth
North Norfolk
Norwich
South Norfolk
Mean
D3MFT
%
D3MFT
>0
Mean
D3MFT
(%
D3MFT >
0)
%
DMFT
0
Care
Index
%
74.1%
46.9%
59.0%
0.74
0.75
0.73
33.4%
31.5%
31.9%
2.21
2.38
2.27
66.6
68.5
68.1
47%
29%
27%
69.6%
53.2%
27.7%
47.4%
1.29
0.92
0.87
0.54
45.6%
35.3%
35.4%
25.6%
2.83
2.62
2.45
2.13
54.4
53.2
64.6
74.4
9%
22%
36%
40%
12-yearold
Population
(Mid-2008)
Drawn
Sample
%
Examined
608,460
8,452
1,387
120,642
1,477
310
1,087
1,103
1,189
1,566
125
365
357
384
Figure 13 compares two earlier survey results, 5 year olds in 2003/4 and 11 year olds
2004/5, illustrating similar trends in decay experience in primary and permanent
dentitions.
90
80
70
60
50
40
30
20
10
0
N
S&
C
St
H
A
Br
oa
dl
an
G
d
re
P
at
C
T
Ya
rm
ou
th
P
N
C
or
T
th
N
or
fo
lk
PC
T
N
or
w
ic
So
h
ut
PC
he
T
rn
N
or
fo
lk
PC
T
W
av
en
ey
PC
W
es
T
tN
or
fo
lk
PC
T
5 Yr Olds
11 Yr Olds
En
gl
an
d
% No Decay
Figure 13 - The Proportion of 5 Year Olds (2003/4) and 11 Year Olds (2004/5)
with No Decay Experience in Norfolk and Waveney PCTs
Source: BASCD Survey Reports 2003/4 and 2004/5 (Pitts et al., 2005 and 2006)
27
Oral Dental Health Needs Assessment for NHS Norfolk
Cleft Lip and Palate
Cleft lip and palate is a phrase used to describe a group of congenital facial
malformations that occur when the upper lip and/or palatal shelves fail to fuse during
embryonic development. There is a range of conditions within this definition from a
simple notch of the upper lip to a full bilateral cleft of the lip and hard and soft palate.
Successful management of patients requires multidisciplinary, highly specialised
treatment from birth to early adulthood including multiple surgeries, genetic and
psychological counselling, speech and language therapy, orthodontics and long-term
preventive and restorative dental care.xiii Orofacial clefts occur in around 1 in 500 live
Caucasian births.vii Clefts occur more frequently in oriental people and less frequently
in those of Afro Caribbean origin.
The local centre for mulitidisciplinary care in the East of England is Addenbrooke’s
hospital, (hub), and ‘spokes’ include the Norfolk and Norwich University Hospital
Foundation Trust, where all of our local children are kept under regular review, co
coordinating audit data with the centre, as set out in national guidance. It has been
observed (Norfolk OHAG, 2009) that routine dental care these children receive may
not always be adequate and that there should be a greater flexibility to ensure their
care in primary care is followed through.
Orthodontic Treatment Need
The recent Children’s Dental Health Survey in 2003 found that 35% of 12-year-olds
in England would benefit from orthodontic treatment.xiv This figure is often used to
plan commissioning of orthodontic services, on the understanding that not all of these
children will seek, accept or be suitable for orthodontic treatment.
In Norfolk there are approximately 9,330 12 year olds (Table 9, Source ONS/Norfolk
County Council) and this number has reduced in recent years and is projected to
reduce further over the next few years, and then increase again. This indicates that
current service levels, if they are meeting current demand are about right. There
may be changes in commissioning in neighbouring counties and knowledge of this
and the potential impact needs to be understood as Norfolk providers treat children
from out of county, and Norfolk children, particularly from West Norfolk, may travel to
Cambridgeshire for their treatment.
Table 9: population projection for number of 12 year olds in Norfolk, with chart.
Source: ONS/Norfolk County Council.
Year
NORFOLK
2006
9,798
2010
9,330
2014
8,471
2018
9,100
2022
9,704
2026
9,573
2030
9,638
28
Oral Dental Health Needs Assessment for NHS Norfolk
NORFOLK
12,000
10,000
8,000
6,000
NORFOLK
4,000
2,000
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
0
Year
Unlike most oral conditions, malocclusion does not vary between genders or social
classes (although racial characteristics mean that there is some ethnic variation).
Despite this, there have historically been inequalities in the receipt of orthodontic
treatmentvii, e.g. girls receive more treatment than boys and adolescents in deprived
areas are more likely to have untreated malocclusion.xv Local data on the prevalence
of malocclusion have not been routinely collected, but the BASCD coordinated
survey of 12 year olds in the academic year 2008/09 had an orthodontic need
component but the results are not yet available.
29
Oral Dental Health Needs Assessment for NHS Norfolk
2.3 Oral Health and inequalities in Adults
Dental caries
The decennial National Adult Dental Health Survey, commissioned by the
department of health through ONS, has shown the dental health of most people in
the UK to have improved dramatically during the past 50 years. This, as with the
dental health of children, is attributed largely to the widespread use of fluoride
toothpaste.xvi. During the post-war years, and when the NHS was established, the
nation’s oral health was poor and dental disease was rifexvii and there was little
expectation that teeth would last a lifetime. This expectation has now changed, with
the proportion of adults with no teeth dropping from 37% in 1968 to 12% in 1998 (see
Figure 14).
Figure 14: The Proportion of Adults with No Natural Teeth in England,
1968–1998
Source:
National Adult Dental Health Surveys, 1968 to 1998. Kelly M, Steele J,
Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E and
White D (2000). In Choosing Better Oral Health, Department of Health
(2005) http://www.dh.gov.uk/assetRoot/04/12/32/53/04123253.pdf
National surveys, conducted decennially, show that adult dental health is improving
and almost a third of young adults (aged 16 to 24 years) have no fillings. More adults
are keeping their teeth into older age and edentulousness is expected to drop to 8%
by 2008.xviii It is predicted that by 2028, around 96% of the population will have their
natural teeth. The proportion of younger adults who have a sound dentition
(i.e. without any restorations or caries) has also improved dramatically, rising from
9% in 1978 to 30% in 1998.xix
The average number of decayed teeth has dropped substantially from 1.9 teeth in
1978 to 1.1 teeth in 1998xx and the proportion of younger adults, with a sound
dentition (i.e. without any dental restorations or decay) has risen dramatically from
9% in 1978 to 30% in 1998xxi. The most recent national survey was undertaken in
2010 and a preliminary report is expected this autumn, with the final report in 2011.
The independent review of NHS dental services in England (Steele, 2009) uses
trends from successive adult national dental surveys to illustrate the ‘heavy metal
wave’(Figure 15) where the younger adult generation of 1978 had high levels of
decay and many fillings, and by 1998, they were in middle age and still exhibited the
highest treatment need and rates.
30
Oral Dental Health Needs Assessment for NHS Norfolk
Figure 15: The heavy metal wave (Steele, 2009)
Populations with high proportions of older people in the future will require significant
resource to maintain past restorations. It could be projected from the figure below
that by 2008, the cohort with the highest treatment need had reached the 55 to 64
age group and so over the next ten years, these people will be included in the
population group 65 years and over.
While oral health has improved generally, it is not all good news. Population
averages hide oral health inequalities, as seen in Figure 15. This highlights that the
prevalence of oral disease is highest in areas of social deprivation.
Percentage
Figure 16: Proportion of Adults with Decayed/Unsound Teeth or
Periodontal (Gum) Disease by Social Class
100
90
80
70
60
50
40
30
20
10
0
62
57
50
42
I, II, IIINM
47
44
IIIM
Decayed/Unsound Teeth
Periodontal Disease
IV, V
Social Class of Head of
Household
Source: Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure
E, White D. Adult Dental Health Survey. Oral Health in the United Kingdom 1998.
Adults from the most deprived areas are more likely to have one or more decayed or
unsound teeth than those from less deprived areas, as seen in Figure 15.
31
Oral Dental Health Needs Assessment for NHS Norfolk
Figure 17: Teeth Condition Among Dentate Adults in England by Jarman Area
Source: Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure
E, White D. Adult Dental Health Survey. Oral Health in the United Kingdom 1998. Available
at URL: http://www.statistics.gov.uk/downloads/theme_health/AdltDentlHlth98_v3.pdf
Attendance for Treatment
Despite the higher level of need in adults from deprived areas, it is adults from the
least deprived areas that are more likely to have restored teeth. This suggests that
those from higher socio-economic groups are more likely to seek dental treatment.
Similarly, individuals from socially deprived groups report that they are more likely to
attend irregularly and only when they have a problem (see Figure 17). Figure 16
shows that much decay goes untreated (even in the least deprived socio-economic
groups the proportion of untreated decay is as high as 50%).
Figure 18: Reported Usual Reason for Dental Attendance of Dentate Adults by
Social Class
Percentage
100
80
II, II, IIINM
60
IIIM
40
IV, V
20
0
Regular check-up
Occasional check
–up
Only with trouble
USUAL REASON FOR DENTAL ATTENDANCE
Source: Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure
E, White D. Adult Dental Health Survey. Oral Health in the United Kingdom 1998.
The Steele Review has explored in depth why people can be reluctant to go for
routine checkups and care. Reasons are common, many and complex often tracing
back to fear, fear of cost, inconvenience, perceived difficulty in finding a trusted
service (especially as people move home and job) and a misalignment of
professional and public concepts of the purpose of NHS care, that includes
preventive advice. There is little direction for patients and increasing demand for
aesthetic work.
32
Oral Dental Health Needs Assessment for NHS Norfolk
Local data on adult oral health are not routinely collected in the UK. In many areas
there is a paucity of local information on adult oral health so measures of child dental
health are the most commonly used indicators of dental disease. The decennial
national surveys do, however, collect data to regional level. The findings of the most
recent adult survey (1998) suggests that oral health inequalities are geographically
clustered; as Figure 19 shows, adults in the South of England tend to have better oral
health than adults in the North.
Figure 19: Dental Status of Adults in England by Region
90
80
Percentage %
70
60
Natural Teeth Only
50
Natural Teeth with Dentures
40
Edentate
30
20
10
Source:
North West
West Midlands
South West
South East
London
Eastern
Trent
Northern &
Yorkshire
0
Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts
N, Treasure E, White D. Adult Dental Health Survey. Oral Health in the
United Kingdom 1998.
Gum (Periodontal) Disease in Adults
It is difficult to collect robust data on periodontal disease; however, national surveys
suggest that the incidence of severe periodontal disease is declining.xxi Nevertheless,
chronic periodontitis still affects a significant proportion of the population. The most
recent Adult Dental Health Survey, in 1998, found that 54% experience chronic
periodontitis. Prevalence increases with age as 14% of 16-24 year olds and 85% of
people aged 85 years and over have signs of the disease. Approximately 5% of the
population suffer from severe diseasexxii and are, therefore, at significant risk of tooth
loss. Periodontal disease is exacerbated by poorly or unmanaged diabetes.
Findings of national surveys suggest that the pattern of oral health inequalities in
gum disease mirrors that of dental decay; adults who have the most severe disease
tend to come from the more socio-economically deprived groups. Figure 16 shows
that groups with the highest need, both in terms of dental decay and periodontal
(gum) disease, come from the most deprived socio-economic classes.
Oral Cancer in Adults
The prevalence of oral cancer had been declining steadily over the past few
decades, but it has recently begun to risexxiii. In 2001, national survey data estimated
that there were 4400 new cases in the UK, making up 2% of all cancers. In 2003,
approximately 1,600 deaths were attributed to oral cancer. While mouth cancers
account for only around 1% of all new UK cancers per year, the incidence is rising
33
Oral Dental Health Needs Assessment for NHS Norfolk
and now accounts for approximately 800 deaths annually. The five-year survival rate
in England is around 50% if the patient presents at an advanced stage. However,
early detection improves five-year survival rates dramatically, to just below 90%.xxiv
Unfortunately, the low awareness of oral cancer among the public, and the painless
nature of oral cancer in its early stages, mean that early presentation is rare. People
tend to only seek treatment when the cancer is more advanced and difficult to treat.
Incidence of oral cancer increases with age from 30 years, although prevalence is
beginning to increase in younger adults.xxv It is twice as common in men as in
women, however, the gender difference is becoming less pronounced over time.
There are wide geographic variations in prevalence and those in lower socioeconomic groups are more susceptible.xxvi
Between 2004 and 2008, the annual average for the East of England was 808 cases,
of which 414 are from the Anglia Cancer Network that includes Norfolk residents.
(Source: Cancer Registry)
34
Oral Dental Health Needs Assessment for NHS Norfolk
Summary points Section 2 Oral disorders and epidemiology
•
Dental decay, periodontal disease and almost all oral cancers are completely preventable
but when they occur have life long effects requiring continued professional input. Hence,
there is good justification to invest in oral health promotion and prevention as evidenced
in ‘Choosing Better Oral Health’
•
Many risks for oral disease are the same as those causing other disease and hence
many aspects of oral health promotion can be dealt with through established wider health
promotion services and initiatives in Norfolk e.g. Health Trainers, Change for Life,
workplace health if the links are made; prevention messages should be consistent.
•
Malocclusions are usually natural variations in the population with about 35% children
above the threshold where treatment might be warranted on the NHS using current
policy.
•
Numbers of 12 year olds are falling slightly hence it is expected that no increase in
orthodontic capacity needed.
•
Dental health of children has improved enormously since the 1970s with well over half
with no decay. Higher disease levels are increasingly concentrated in lower income
groups but are still seen across society.
•
It is important that local survey work is explicitly commissioned. The most recent dental
survey results presented a rosy picture of child oral health but because of national policy,
children could only participate if their carer gave consent. The ‘care index’ has shown
that amongst children surveyed, much disease is not treated but this is not unique to
Norfolk. It would be useful if similar consent policy was used as it is with the height and
weight measurement programme, i.e. opt out rather than opt in.
•
The current dental contract is designed to give dentists enough time to use preventive
techniques. Commissioners can recognise the benefits of supporting ongoing
development for dental health professionals do this effectively.
•
Children with cleft lip and palate deserve the highest standards of general dental care.
•
Among adults, numbers with no teeth at all are very low and confined mainly to the oldest
members of society. Most people now should expect to retain their teeth for life; older
adults have restored dentitions that require careful maintenance; there should be good
access to specialised advice and care. Many young adults have no fillings at all. Disease
patterns reflect economic deprivation.
•
There is evidence that higher socio economic groups are more likely to seek dental
treatment and that people who go only when they have a problem are more likely to be
from a more vulnerable background. Increased focus on patient views will be valuable for
future commissioning of dental services but currently we must ensure that appropriate
information on services is available.
•
To enable access of services to all, it is really important that local dentists agree with
each patient a recall interval appropriate to their risk of needing professional input. NICE
guidelines are very clear on what is required and how it is done. NHS Norfolk needs to
work collaboratively with the profession locally to ensure this takes place.
35
Oral Dental Health Needs Assessment for NHS Norfolk
Section 3: Factors affecting Oral disease and approaches to
prevention
3.1
Biological and social determinants
The factors underlying the development of poor oral health are well known to the
public and the underlying science is well researched and understood.
The main biological risk factors are:
•
•
•
•
•
Poor diet and nutrition:
High consumption of free sugars leads to dental caries.
Poor nutrition can increase risk of oral cancer.
Poor oral hygiene:
Poor plaque control will increase risk of dental caries and gum disease
Lack of exposure to fluoride:
Regular exposure to fluoride has a protective, anti-caries effect.
Tobacco and alcohol:
Smoking increases the severity of gum disease and is one of the main
risk factors for mouth cancer. Smoking combined with excessive
alcohol consumption leads to a much greater risk of cancer than either
in isolation.
Injury:
Injury to teeth can occur through accidental injury or violence or
contact sports.
Social approaches (Figure 20) can reduce risks across a whole population. Policy
that makes it easier for everyone to have good diet, exposure to fluoride and good
oral hygiene will have a relatively greater benefit for vulnerable population groups, as
long as the policy takes account of their needs. Key vulnerable groups and how their
differing needs require a more tailored approach are described later in this section.
Policy on food and nutrition already recognises dental health issues. For example
breast feeding is promoted; breast milk does not cause dental decay. However,
fluoride, both in water supplies and through brushing with fluoridated toothpaste,
protects against tooth decay but there is controversy about adding fluoride to public
water supplies. Norfolk does not have its drinking water fluoridated and as it is
harder to assure use of toothpaste amongst vulnerable population groups, targeted
promotion of use of fluoride toothpaste can be commissioned, for example through
Sure Starts, for young children. All policies to reduce smoking and alcohol use will
improve population oral health. Health and safety policy, plus accident reduction
policies, such as compulsory seatbelt use, safe play areas and use of mouth guards
for contact sports reduce risk of injuries to teeth.
Supporting individual lifestyle choices (e.g., for dental health, choosing food/drink low
in free sugar, and infrequent snacks), should be encouraged where there are existing
opportunities, e.g. patients seen regularly because they are on a GP risk register, or
those in contact with Health Trainers. For the population that attends a dentist, an
individualised discussion can take place at the chairside.
36
.
Oral Dental Health Needs Assessment for NHS Norfolk
Figure 20: The Underlying Causes of Oral Health
Source: Modified from Watt, 2005 in Department of Health Choosing Better Oral Health. An
Oral Health Plan for England. 2005 Available at URL:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanc
e/DH_4123251
3.2
Using the Common Risk Factor Approach to tackle inequality
Tackling the risk factors of oral diseases and promoting oral health, with appropriate
targeting for vulnerable groups will reduce population oral health inequalities. It is
important to acknowledge that the provision of high quality dental services is only one
aspect of this as dental services are, by necessity, treatment focused and will not
eliminate oral disease or health inequalities alone, no matter how accessible or
effective they may be.
The most powerful promotion of oral health is through collaboration, where possible,
of oral health promotion with generic health promotion, as described in Choosing
Better Oral Health (Section 4). The Common Risk Factor Approach emphasises the
need to tackle the common risk factors and conditions that are shared by common
chronic non-communicable diseases.xxvii As illustrated in Figure 21.
The common population health risks that include a major dental risk are poor diet,
smoking, stress, high alcohol consumption, poor hygiene and injuries. Targeting the
reduction of these risk factors at a population level (as is happening in NHS Norfolk)
as well as to key groups would simultaneously reduce the incidence of obesity,
health disease, stroke, cancers, diabetes and mental illness, in addition to oral
diseases. If the Common Risk Factor Approach is broadly adopted, it has the added
advantage that all health professionals will communicate consistent health messages
to the public. Strategic approaches to improving oral health will therefore be linked to
other, more general, health promotion initiatives.
37
.
Oral Dental Health Needs Assessment for NHS Norfolk
Figure 21: The risks, common between oral and other chronic diseases
s
Source: Sheiham and Watt, 2000 in Department of Health Choosing Better Oral Health. An
Oral Health Plan for England 2005 Available at URL:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanc
e/DH_4123251
The evidence base for dental service advice and care on prevention is published in
‘Delivering Better Oral Health’ (2009); every dentist in England has been sent a copy,
directly from the Department of Health. Within dental services, dental health
promotion is delivered through the main dental contract, by dental healthcare
professionals to individuals who access it. In addition, the salaried services have a
dedicated health promotion service that liaises with other professional groups such
as teachers, Sure Start staff and health visitors and now stop smoking services,
health trainers and other public health services. This service can also work one to
one with patients treated by salaried service staff, who are as such from vulnerable
groups. Other examples of health protection work includes:
Diet:
Advice on healthy eating for dental health is aligned with government policy on
general healthy eating advice. All teams giving healthy eating messages are likely to
be giving the right message for oral health, but there is a role to always check for
this. Advice specific to oral health, and evidence for this, is in Choosing Better Oral
Health.
38
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Oral Dental Health Needs Assessment for NHS Norfolk
Overweight and Obesity
Any association between dental caries and obesity has limited supporting evidence
at this time.xxviii. However, part of obesity prevention is dietary advice.
A person is described as overweight or obese if their body mass index (BMI) exceeds
certain levels. BMI takes account of both weight and height. The Norfolk Health
Profiles highlight 1:4 – 1:5 adults in Norfolk being obese.xxix which is very slightly
lower than the England average. The National Child Measurement Programme
figures for NHS Norfolk in 08/09 showed 9.1% of children at Reception year age and
18% in year 6 to be obese. And local analysis has estimated one in 3 or 55,000
children (0-15yrs) who are overweight or obese.
Figure 22 shows the distribution of childhood overweight and obesity, charted from
the 2008 National Child Measurement Programme. Areas with the darkest shading
are the highest fifth in terms of prevalence of these conditions. Many are in rural
areas, particularly in West and North Norfolk, where services such as schools and
libraries are sparse, the problem seems to be more widespread. It is likely that diet
along with a lack of active travel opportunity is a significant factor in this.
Figure 22: Year R and Year 6 % overweight and obese 2007 – 2008 in Norfolk
(source: National childhood Measurement Programme)
Policies across government are increasingly focussed on stemming the rise of
obesity, using the common risk factor approach and NHS Norfolk is fully engaged in
this, e.g. through the Change 4 Life Programme. Targets in NHS Norfolk’s Strategic
Plan, Bold and Ambitious, aim by 2014 to achieve a 2% reduction in the number of
obese primary school, and a 4% reduction in the number of obese year 6 children.
Salaried dental service health promotion teams have a role to ensure that advice
39
.
Oral Dental Health Needs Assessment for NHS Norfolk
given to the public is consistent, and do not compromise the dental health message
but can support local initiatives to improve oral health.
There is a small but increasing number of people with morbid obesity (numbers are
not known), which severely compromises medical and physical health, such that
providing dental treatment, and indeed other healthcare, can become problematic.
For example, the person presents as a higher risk if they need sedation or a general
anaesthetic, or domiciliary care might be required. Individuals should be assessed
and treated on an individual basis, dependant on need.
Smoking
The estimated proportion of adults who smoke in Norfolk is 22.7%, not significantly
different from the England average of 22.2% (Source: Norfolk County Health Profile,
2010). However, the East of England Lifestyle Survey 2008 estimated smoking
prevalence to be only 18.9%, similar to a regional average of 18.4%. Smoking or
chewing tobacco can affect oral health in a number of significant ways. These
include increased risk of oral cancers and pre-cancers, increased severity of gum
disease, premature tooth loss and poor wound healing. It is difficult to demonstrate
this at a local level due to the long term impacts. Oral Cancer figures for the Eastern
Region are over 800 per year, of which 414 are dealt with through the Anglia Cancer
Network. It would be useful to track future incidence of this catastrophic disease as
smoking rates fall.
In 2009/10, Norfolk Stop Smoking Service achieved 4434 4 week quits, 30% of which
were in the 20% most deprived areas (MSOAs). In May 2007, the Department of
Health published Smokefree and Smiling: helping dental patients to quit tobacco’ as
part of their ongoing campaign to involve dental teams in supporting people to stop
using tobacco.xxx The local stop smoking service has linked with dental practices and
is working closely with them and this work should be recognised and encouraged.
Alcohol
The Norfolk Health Profile reports rates of binge drinking, which applies usually to
young adults.xx There is increasing concern over excessive alcohol use by older age
groups.
A report from ERPHO in 2008 on Mental Health in Norfolk identified 11 255 alcohol
related inpatient admissions in 2005.
There is a well-recognised relationship between alcohol misuse and oral disease.
Research suggests that patients suffering from alcohol use disorders experience
poor oral health (including significant levels of dental caries, gingival inflammation,
soft tissue abnormalities, tooth erosion and an increased risk of developing
periodontal disease).xxxi Excessive alcohol use is also a significant risk factor for oral
cancer. Of particular concern is the synergistic action of excessive alcohol
consumption with tobacco (smoked and chewed), which when used together, will
substantially increase the risk of developing oral cancer.xxxii
Drug Abuse
Intravenous drug use is associated with poor oral health, in particular dental decay
and periodontal disease. This is thought to be due to a complex relationship
between a number of factors, which include poverty, self-neglect, consumption of
high sugar foodstuffs, poor oral hygiene and the intake of methadone syrup.xxxiii,xxxiv
Prolonged drug use is often associated with self-neglect and a cariogenic (decay
40
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Oral Dental Health Needs Assessment for NHS Norfolk
promoting) diet.xxxv There are indications that drug addicts experience severe dental
and periodontal tissue destruction.xxxvi
In comparison with the general population, drug users tend to have poorer oral health
and display lower utilisation of dental servicesxxxvii. Not everyone is known to the
dental services; those who are frequently have the severest problems and are
defined as problematic. Many chaotic drug misusers are homeless and have a
history of offending, making the organisation of their care very difficult. There are just
over 1000 people currently registered for intense support and these people have the
severest problems. They complain of dental pain that can sometimes cause them to
relapse from abstinence. Furthermore, they may have blood borne disease and
hence fear stigmatisation if they present for treatment to the dental services. In
Norfolk there were 2,991,15 to 64 year olds who were problem drug users (source
ERPHO, 2008) Data from the National Treatment Agency confirm that this is fewer
than the England average population rate which is (9.9/1000), this group has special
dental needs and require greater access to dental care than most. The barriers they
face are common to many, but relatively greater; in the knowledge their dental health
may be poor and neglected, they can feel that they will be stigmatised by dental staff.
Many fear pain, needles, and costs. Those otherwise rehabilitated and ready to
develop their lives can find particular frustration in obtaining appropriate sympathetic
care for their high treatment need. It is important that services can liaise with
treatment/offender services to help the most chaotic people, and that access to
services across the county is simple.
3.3
Populations in special situations
It is clear that despite substantial improvements in oral health, marked inequalities
remain, with socially deprived and/or vulnerable groups in society with poorer oral
health and poorer access to oral health care services, although they may be exempt
from paying dental charges.
Groups of people particularly at risk from oral diseases include the following:
People living in areas of material and social deprivation
Norfolk has some significant sectors of the population with income deprivation
(Figure 8). Several public health programmes in Norfolk target these groups by
geographical area, e.g. Joy of Food, Sure Starts, health trainer services (that link into
people in the fifth quintile, who are identified in the newly established Health Checks,
a GP commissioned service). People identified by the health checks receive
lifestyle/behaviour change advice. They may have a history of non attendance at a
dentist and a high unmet oral health need. Community workers usually have a good
knowledge of oral health risks, but they report a lack of resources such as
information on the subject tailored for their group, and knowledge on where to direct
people for appropriate and sympathetic healthcare. The dental contract has been
unable to incentivise all but the most dedicated dentists to prioritise high need
groups, where individuals may require a lot of time and skill, and may miss
appointments. The success of the Siskin centre and the access service in Kings Lynn
in providing services for these groups is acknowledged and valued by those
providing the targeted support to vulnerable groups. However, such services are
lacking in Thetford, so patients have to travel to access these centres.
Oral health begins at birth, and it is important to promote uptake of breastfeeding
alongside healthy eating particularly for these groups as breast milk does not cause
dental decay where as the effects of sweetened bottled drinks once teeth erupt, are
devastating.
41
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Oral Dental Health Needs Assessment for NHS Norfolk
The salaried dental service formerly targeted schools for dental inspections where a
high percentage of children received free school meals. Information on what is
provided locally is in the service delivery section of this report, collected through
service monitoring information.
Looked after children
At any one time there are just over 900 children looked after in Norfolk, i.e. where a
local authority is the corporate parent. It is particularly important that dental care
needs are not overlooked for this vulnerable group.
The Children and Families Programme Board has been contacted by NHS Norfolk
and the overseeing manager has confirmed that that oral health is a topic of annual
discussion for each child and that regionally, the use of fluoride varnish for this group
is being promoted. It is recommended that this is supported in Norfolk through
enabling training, and particularly encouraging salaried services to make this service
available and to target it according to the guidance in ‘Delivering Better Oral Health’.
People who have learning disability
Individuals with disabilities experience more oral disease and have fewer teeth than
the general population. They also have greater unmet dental needsxxxviii as they have
more difficulty in accessing dental care.xxxix Access to oral health care is affected by
where people with learning disabilities live. Evidence suggests that 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 servicesxl. A detailed assessment of general health need in Norfolk has been
commissioned and is due for completion later this year and most medical practices
either have a register, or have arrangements with a neighbouring practice, of their
patient’s with learning disabilities known to health services. Registrants have an
annual health review which includes recommendations for accessing regular dental
care. This is in line with guidance: Valuing People Now. (Department of Health).
Many of these people with the severest problems already have good dental care and
the Salaried services are mentioned by special needs services providers as being
very good, particularly those at the NNUH, North Walsham, the Siskin Centre and at
Kings Lynn. Staff have demonstrated appropriate understanding and skills. Part of
mainstreaming patients with learning difficulties, however, is to ensure that all
services commissioned, where possible can provide proportionate care. This
promotes better diversity of choice for the patient, freeing up the most specialised
aspects for only those with severest need. Salaried/specialised services in this field
should work proactively with generalist dental practices to promote dental pathways
appropriate for the individual and to enable patients to seek at least their routine
dental care as close to home as possible.
There are many more people with less severe learning difficulty, and this group might
not be recognised by health services as such, and these people can misunderstand
messages, including appointment arrangements, and find it difficult to act on
preventive advice. It is wrong to generalise, however, these people are more likely to
live in areas of deprivation, and access care only when they feel they need it, and for
example when they have a dental problem. It is crucial that access is maintained
sensitive to the needs of this unquantifiable group. Work is being undertaken
through the learning difficulty needs assessment to predict numbers with mild
learning difficulty by using predictions from numbers of statemented children in
schools. This data is not yet available for NHS Norfolk.
42
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Oral Dental Health Needs Assessment for NHS Norfolk
People with mental illness
The Eastern Region Public Health Observatory, ERPHO (2008) published indicator
data on mental health in the general population of NHS Norfolk. There were:
• 11,360 claimants of incapacity benefits due to mental health conditions in
2006.
• 241 admissions for schizophrenia in 2005/6
• 2,991 - 15 to 64 year olds who were problem drug users
• 11, 255 alcohol related inpatient admissions in 2005
• 2,172 people on enhanced or standard care programmes.
• Of 11,248 people aged 18 to 61. 2,661 were on either standard or enhanced
care programmes.
Recent national policy has recognised gaps in services for people with Autism and
Aspergers Syndrome. These people are at risk of finding dental care unacceptable
and dental teams may be poorly equipped to help them. The Salaried services have
staff that understand the needs of this group and should be available if difficulties are
encountered at general practices, and the situation monitored through patient
feedback.
The ERPHO report emphasised the evidence that employment is beneficial to mental
health and that people who have been abused, been victims of domestic violence or
who have drug or alcohol problems are more likely to suffer mental health problems.
There are higher rates of mental health problems within black and minority ethnic
groups and high rates in prison populations. Between a quarter and a half of all
homeless people have a serious mental disorder and are alcohol dependent.
Frail Elderly
Older people have specific oral health needs as oral health problems increase with
age. In particular, age related changes can lead to xerostomia (often drug related),
root caries, recurrent decay and decreased manual dexterity can lead to reduced
plaque control. Systemic problems can also have an effect on oral health, for
example, many older people suffer from progressive neurocognitive impairing
illnesses (e.g. Parkinson’s disease and Alzheimer’s disease) which will cause
difficulties in controlling and retaining dentures.xli In older people, the retention of
natural teeth into old age makes a major positive contribution to the maintenance of
good oral health related quality of life and there is a clear and consistent relationship
between retention of natural teeth and a healthy diet and good nutrition.xlii
Dental care for frailer older people may require extra skill and take longer than for
other people. Some live in residential settings (see below) but a good many live in
the community (see Figure 6) and so a wide range of service options need to be
available to them.
People in long term institutional care (including residential homes, psychiatric
hospitals, prisons)
a) Residential homes
In terms of end of life residential care, the Care Quality Commission regulates
residential care homes. In 2009/10 there were approximately 387 homes registered
in Norfolk, of which 110 had capacity for dementia patients and 67 offered nursing
care. The total capacity was 9,388 places (source: NHS Norfolk).
43
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Oral Dental Health Needs Assessment for NHS Norfolk
These are mapped on Figure 23 and are widely distributed across urban and rural
settings. More remote settings may experience staffing difficulties and retaining
trained staff.
Figure 23: map of residential and care homes: Source NHSN 2010
An indication of the number of social services funded places across these homes is
shown on table 10. Numbers related to those aged 65+ in Residential and Nursing
Care on 30/06/2010:
Table 10: places commissioned by Norfolk Social Services for people aged
65+in residential and Nursing Care on 30/06/2010.
Care type
Number
3,083
535
3,618
Residential
Nursing
Total
The remaining places are self funded, but may be commissioned from neighbouring
authorities, in which case NHS Norfolk remains responsible for commissioning
suitable dental services.
It is expected that residents in institutions have access to dental care; the first choice
is that they make an outing to visit a surgery, where care provision is optimal.
Expecting a domiciliary visit is a last resort as the range of care that can be provided
is limited. It is also not a cost effective way of providing a service. Where domiciliary
care is required, and this equally affects housebound people as well as those in
institutions, there should be a choice of provider. In Norfolk there is a contract with a
PDS provider, plus services from the salaried service. It is unclear how patients
access either, other than by knowledge of the services or referral from a doctor or
dentist. It is likely that some sectors of this population will be unaware of the options
open for their residents. It is important that care home managers are aware of oral
health and healthcare issues and information/advice needs to be targeted to this
group, and local training available for care workers.
44
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Oral Dental Health Needs Assessment for NHS Norfolk
b) Psychiatric care
The Mental Health National Minimum Data Set for 2008/9 records for Norfolk that
11,258 people used mental health services for adults or older people and of these,
1,314 patients were detained. Length of stay can be protracted and the average
daily bed occupancy was 312. These patients need access to dental care, and
currently this is provided by the salaried dental service. The service also provides
care for residents of the medium secure unit at Thorpe St Andrew.
c) Prison populations
The standard of oral health in prison populations is significantly worse that of the
general population.xliii Norfolk has three prisons with the following numbers:
Table 11: Prisons in Norfolk and occupancy, 2010
(Source: Prison Commissionner, NHS Norfolk)
Prison
Norwich
Bure*
Wayland
Total
Prisoner number
767
520*
1,017
2,304
*Possibly an extra 100 next year, bringing the total in Norfolk to 2,404.
.
Turnover of inmates and mobility between prisons complicates health care
management. Prison is an opportunity to offer access to care for disadvantaged
groups who would normally be hard to reach. Not only should effort be made to
improve the health of the individual but also to influence the health and wellbeing of
prisoners' families and the wider community.
Prisoners tend to have more decayed teeth, fewer filled teeth and less natural teeth
than the general population, even when social class is taken into account (adults in
social classes IV and V have been shown to have fewer decayed or unsound teeth
than the prison population).xliv Evidence suggests that there is a substantial amount
of unmet need in British prisons.xlv Summary data show prison dental health to be
four times worse than the average population.
Prison dental services now operate to a new contract, with quality markers. The
service is staffed by people from the salaried dental service. Services are developing
in a way integrated to overall healthcare of prisoners, using a triage system to
prioritise those in greatest need. Needs are confirmed by the service providers to be
high. There is a need for better targeted information for health trainers and the
probation services to use when working on prevention.
Homeless people
Homeless people tend to have poorer health than the rest of the population. Often
concentrated in city centres, where hostels are located, this group of people often
have high proportions of people with history of mental illness, substance misuse and
previous prison sentence. However, this is far from the whole picture as some
people remain unknown to authorities, staying with friends or frequently moving.
Data on the oral health status of homeless individuals is limited; however studies
consistently report a high clinical and perceived need for oral health care within this
populationxlvi. They have a higher dmft (decayed, missing and filled teeth) than the
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Oral Dental Health Needs Assessment for NHS Norfolk
general population and there is a greater prevalence of dental pain and periodontal
(gum) disease.xlvii Homeless people tend to have fewer remaining teeth and heavy
plaque accumulation.xlviii Despite these high levels of need however, homeless
people experience difficulty in accessing dental servicesxlix
Health services targeted to this group include City Reach. This service has good links
with the salaried dental service and engages with any NHS practice convenient for
their client. City Reach is working with about 450 clients at any one time, with a turn
over of 40 to 50 people per month. A problem highlighted is that these people are
unlikely to be registered with authorities and hence cannot claim exemption from
dental charges.
Ethnic groups with evidence of social disadvantage
Data on the oral health of ethnic groups are not routinely collected in the UK
therefore a comparison of their oral health status is limited. Reasons why oral health
may be at increased risk include lack of access, knowledge of or communication with
care or advice and cultural issues.
It is important to consider the cultural characteristics of each subgroup particularly
when designing oral health promotion activities for diverse ethnic groups. Data in
section 1 (Fig 7a and 7b) show the comparatively smaller proportions of these groups
in the Norfolk population, which increases the risk of them being overlooked.
Migrant workers
Substantial communities of migrant workers within Norfolk are known to be in
Thetford and Kings Lynn, where health trainer services help link families to
mainstream services, often the first port of call being the salaried dental services.
The Health Trainer service has suggested that commissioners can promote
collaboration between family dental services and salaried dental services through
commissioning information, and also by ensuring services that these people may
prefer, that might include drop in and out of hours sessions and time to explain how
NHS dental services and their charges operate.
There are many more migrant workers, dispersed, often working in the private sector;
employers can be reached through business partnerships such as the Local Strategic
Partnerships at District and County level and individual families may access other
health care services, such as A&E or through registration with a GP.
Asylum seekers
Clearsprings has 150 beds for asylum seekers, as part of trans UK arrangements.
All clients are offered medical appointments and the dental practices involved have
good links with local interpreter services.
Travelling community
There is very little published literature on the oral health of Travellers. While there
are no robust data on the prevalence of oral disease in this population, it seems
reasonable to assume that disease levels will be relatively high, as this is a socially
deprived group. A small study in East Hertfordshire in the early 1990s found that
70% of traveller children had dental caries.l The group made little use of preventive
services with the majority of travellers neglecting to visit a dentist regularly. Those
who do are more likely to be settled and literate. Travellers report going to the
dentist mainly when they are in pain.l
Healthcare services for the travelling community in Norfolk have been a focus for
development in recent years and it is important that dental services continue to be
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Oral Dental Health Needs Assessment for NHS Norfolk
supported in their involvement. Services report a high level of dental care need.
Arrangements have been more successful at official sites, but there are more
problems for people who use unofficial sites.
Summary Points – Section 3
Biological and social determinants of oral health
•
Biological determinants of oral health are diet, oral hygiene, reducing tobacco and
alcohol and reducing risk of injury. Fluoride protects teeth against decay.
•
Particularly vulnerable people, such as drug misusers or people with mild learning
disabilities, live across the county, often, but not always, concentrated in areas of
greatest deprivation. Services need to be appropriate (e.g. drop in as well as
mainstream) and accessible.
•
Social approaches through policy and cultural change, such as encouraging healthy
food choices and smoke free places will protect and maintain population oral health
•
There are major initiatives in Norfolk to tackle obesity, smoking, alcohol and drug
misuse. Dental public health needs to link to these.
•
Water fluoridation, which would reduce dental decay, does not have public support
but a lot can be done to support individual lifestyle choices, e.g. use of fluoridated
toothpaste, that reduce an individual’s risk of oral disease.
Populations in special situations
•
People living in areas of material and social deprivation
Geographical areas with the greatest socioeconomic deprivation already have
targeted health improvement initiatives. Dental services need to be proactive to meet
needs identified. This is currently most evident with salaried services.
•
NHNN needs to ensure oral health messages are consistent and that there are
adequate drop in and urgent services along with capacity to complete extensive
courses of treatment.
•
Leaflets and information appropriate for specific client groups, produced locally would
be helpful.
•
Current arrangements for school dental inspections should be reviewed in the light of
potential outcomes.
•
Targeted fluoride varnish schemes for children, especially those with special needs,
should be considered, including through liaison with social services.
•
Looked after children:
Links have been made with the manager of the service; oral health issues are part of
a regular review for each child. Links should be maintained with this service, possibly
through the health promotion team in the provider arm.
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Oral Dental Health Needs Assessment for NHS Norfolk
•
Learning Disability
Good liaison with local dental services is required, especially in planning
appointments. People with severe LD can have a carer to accompany them and their
knowledge and understanding of both personal and professional dental care services
is important.
•
NHSN should aim for good access to services around the whole county, both for
continuing care and for ‘drop in’ style services for those who prefer treatment only
when there is a problem.
•
Better information should be available on this complex group by the end of 2010
through the JSNA, on completion of a project.
•
Mental illness
It is important that good mental health is promoted across society, and that, by
services are patient focussed, people with mental illness are recognised and treated
with respect and dignity.
•
Special issues might include failure to attend for care, phobias and dental neglect.
•
Frail elderly
These people live across the county and may take longer to see and treat than, for
example, a young adult.
•
Domiciliary care might be appropriate, but only where the full benefits of a clinical
setting are truly inaccessible to the person.
•
Long term institutional care
There are almost 10 000 older people receiving institutional care in homes across
Norfolk. It is important to work with home managers to develop and promote
guidance that is backed up by appropriately tailored services.
•
Just over 1,000 people are detained with mental health problems per year. If these
are long stay, then dental services must be as available to them as the rest of the
population.
•
The prison population is over 2,000 and their dental services must be as available as
they are to the rest of the population.
•
For the offender population that is frequently in and out of prison, there should be
continuity of care where possible, and this can be achieved by dental service
providers working proactively with offender services.
•
Homeless People
There is no definitive data on numbers of homeless people, but services such as City
Reach cater for a proportion – about 450 per month that includes a turn over of 40 to
50.
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Oral Dental Health Needs Assessment for NHS Norfolk
•
Dental services need to be flexible to meet the individual needs of clients who will find
it difficult to keep appointments and are likely to have dental health much poorer than
the average person e.g. drop in style services
•
A key barrier to services is that exemption from dental charges cannot be
demonstrated.
•
Ethnic groups with social disadvantage
These are likely to be clustered where there is other disadvantage and hence may be
targeted with other health promotion initiatives.
•
It is important that approaches and information are culturally sensitive.
•
•
•
Migrant Workers
Collaboration with health trainers working with these groups would be helpful.
Culturally sensitive local information on services would be useful, along with good
drop in and out of hours care, with information and guidance to encourage uptake of
mainstream dental services.
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Section 4: Prevention Services
4.1 Water fluoridation
Adding fluoride to water supplies has a demonstrable long term benefit to population
dental health, with no adverse effects. Populations in the North East and
Birmingham have benefitted for many years.
Water fluoridation is defined as “the controlled adjustment of a fluoride compound to
a public water supply in order to bring the fluoridation concentration up to a level
which effectively prevents caries”.xxi The optimal concentration in temperate climates
is 1 part per million (ppm). Approximately 10% of the UK population (6 million people)
are currently receiving water with a fluoride content adjusted to the optimal level
(including naturally and artificially fluoridated areas). The water supply to Norfolk is
not artificially fluoridated and the naturally occurring levels were last analysed by
Norfolk PCTs in 2003.li (Table 12)
Table 12 – Natural Water Fluoride Levels in Norfolk Parishes 2003
Local
Authority
Area
Low Fluoride
(<0.3ppm)
Intermediate Fluoride
(0.3-0.7ppm)
Attleborough, Beetley, Dereham South,
Dereham North
Swaffham, Thetford North, Weeting
Aylsham, Foulsham, Hellesdon,
,Reepham
Broadland
Hoveton, Lyng, Mancroft, Plumstead,
Sprowston
Aylsham, Beetley, Cromer, Fakenham,
Happisburgh, Holt,
North
Hoveton, Martham, Mundesley, North
Stalham
Norfolk
Walsham, Sheringham, Wells
Bowthorpe, Heigham, Sprowston,
Brundall
Norwich
Lakenham, Mancroft, Plumstead
South
Heathersett, Kirby Cane, Lakenham,
East Harling, Harleston,
Norfolk
Poringland, Wymondham
Long Stratton, Mattishall
Docking, Downham Market, Feltwell,
Grimston, Hunstanton, King's Lynn,
West
Leziate, Marham, Middleton,
Norfolk
Sandringham, Snettisham, Swaffham,
Wisbech
Source: Data supplied by Anglian Water and Essex and Suffolk Water, reported in
Murphy, 2003.
(Data for 1992 shows similar fluoride levels, suggesting the change since 2003 may
have been minimal).
Breckland
The best available evidence suggests that the fluoridation of drinking water reduces
the prevalence of caries, both in terms of the proportion of children who are caries
free and by the mean change in dmft. There is also evidence to suggest that water
fluoridation reduces the severity of caries (as measured by dmft) across social
groups and between geographical locations.lii Research has shown that socially
deprived areas benefit more from fluoridation.liii Water fluoridation is consequently
one of the few public health interventions that directly reduce health inequalities.
Following a local oral health needs assessment PCTs may elect to fluoridate their
water supply in order to reduce oral health inequalities. Until recently, water
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companies have had the right to refuse to fluoridate, which has limited the number of
people in the UK receiving fluoridated water. This changed with the Water Act 2003,
which gave Strategic Health Authorities (SHAs) the authority to make this decision,
following a public consultation. Public opinion has made such decisions very
controversial as seen when South Central SHA decided to fluoridate Southampton
and surrounding areas two years ago. The outcome of a judicial review is still
awaited.
In the recently published best practice guidance on Fluoridation of Drinking Water,
the Department of Health states that water fluoridation schemes would ideally ‘serve
precisely only the high-need target population’ where the prevalence of disease is
high, although it is likely that any scheme will also serve some areas with low decay
levels. A further consideration is that any feasible scheme may cross PCT and SHA
boundaries necessitating a joint consultation process.
4.2 School dental inspections
The Functions of Primary Care Trusts (Dental Public Health) (England) Regulations
2006 specify that a Primary Care Trust must provide or secure provision of the
following, that it considers necessary to meet all reasonable requirements within its
area for dental inspection for pupils in attendance at schools maintained by local
education authorities.
These services are commissioned by Norfolk Community Health and Care, but at a
minimal level such that only special schools are covered.
The new government lists child health as a priority and it is anticipated that greater
interest will be shown in school dental inspections as a way to increasing access to
services for those in socioeconomically deprived areas. Schools have historically
been selected where there are a high percentage of children eligible for free school
meals.
The report on current dental activity will provide information on the extent of school
dental inspections carried out by the salaried service in Norfolk.
4.3 Dental Check ups
Dental check ups are listed in the Marmot Review as a preventive service. These
are costed at over £900K per year across England and are the biggest single
contributor, possibly more costly than immunisation programmes. Each dentist has
an evidence based tool to deliver preventive services (Delivering Better Oral Health,
2009) that covers assessing disease risk and recommended preventive interventions
for different population groups.
Correctly applying the NICE guidance on recall interval between dental check ups will
ensure that this valuable resource is targeted more appropriately so that those
regular attendees with low treatment need are seen relatively less often, and hence
there will be capacity to provide more services to people who have not regularly used
services before and are likely to have a higher treatment need.
Service data on access shows how many different people have passed through
primary dental care services in a two year interval, which is a time interval within
which most people would be expected to attend to receive routine maintenance, care
and advice. In Norfolk about 58% of the population have attended an NHS dentist,
and a further unquantified sector will pay for care privately.
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Early stages of dental disease are symptomless and a professional dental inspection
can detect things going wrong at an early stage, resulting in a less damaging long
term effect and less costly interventions.
4.4 Oral health promotion
As described in Section 3, to improve and standardise preventive advice in the
clinical setting, the Department of Health has sent to each dentist in England a
manual, ‘Delivering Better Oral Health’ (updated 2009) which guides the dentist
through assessing disease risk for each patient and then assigning evidence-based
advice and actions. There is evidence that regular professional application of fluoride
varnish, outside the surgery setting, has a preventative effect. This has been taken
forward in some parts of England through commissioning trained staff to provide a
service from supermarkets in school holidays. It could equally be offered at Sure
Starts (for children).
The national oral health strategy is Choosing Better Oral Health: an Oral Health Plan
for England ‘Choosing Better Oral Health’ provides a good practice framework for
tackling oral health inequalities. For example to reduce oral health inequalities in
young children the focus is on two main areas - ‘diet and nutrition’ and ‘oral hygiene’
(see Figure 23). In line with the Common Risk Approach, oral health promotion is
incorporated into generic health promotion where possible; to ensure that consistent
health messages are given.
To this end, promotion of oral health in children requires partnership working from the
following stakeholders:
•
Dental teams
•
Public Health specialists
•
Oral Health Promotion Team
•
Health visitors
•
Health improvement specialists
•
Sure start and children’s’ centres
•
Healthy schools programmes
•
Local authorities
•
Voluntary groups
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Figure 24: Oral Health Promotion Activities Aimed at Reducing Oral Health
Inequalities in Young Children
ORAL
HYGIENE
DIET AND NUTRITION
TOPIC
FOCUS
INFANT FEEDING
POLICY
GUIDELINES
SUGAR CONTENT
PUBLIC
INFORMATION
AND SUPPORT
EARLY
TOOTHBRUSHING
BODY AND ORAL
HYGIENE
TRAINING AND
SUPPORT
GOOD PRACTICE
•
Promote breastfeeding
•
Coma recommendations
•
Oral Health input into local infant feeding strategies and guidelines
•
Promote the development and adoption of nutrition and healthy eating guidelines
•
•
•
•
•
•
•
•
•
•
Discourage addition of sugars to weaning foods/drinks and vitamin supplements
Encourage reduction in sugar content of soft drinks/breakfast cereals,
confectionary, etc.
Encourage caterers to reduce sugars in prepared foods
Encourage vending machine providers to include sugar-free choices
Improve consistency of all dietary messages re: importance of reducing the
frequency of consumption of sugary drinks and foods
Ensure effective dietary education for those at risk of dental caries and erosion
Restriction of promotion of food and drinks high in sugar, particularly for children
Encourage parents and carers to start tooth brushing with fluoride toothpaste within
the first year of a child’s life
Incorporate oral hygiene teaching into Personal and Social Education teaching
Improve the effectiveness of oral hygiene instruction provided by oral and health
professional
Source: Adapted from Department of Health 2005 Choosing Better Oral Health. An Oral Health Plan for
England. London: Department of Health. Available at
URLhttp://www.dh.gov.uk/assetRoot/04/12/32/53/04123253.pdf
Discussion with the Health Promotion team at NHS Norfolk (July 2010) identified the
following examples where targeted oral health promotion either exists or could be
improved:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Joy of food programme
Breastfeeding initiatives
Healthy Start
Midwives
Sure Start
Drug and Alcohol team
Mental Health teams/CAMHS services
Services for those with Learning Difficulty
Health information leaflet service (supplies to service providers, not directly to
public); in particular that the range of information could be increased if it was
commissioned, as currently only ‘free’ high standard (usually government)
information is available.
All members of the primary care community teams, including health visitors
and social workers
Gateway (resettled refugees)
Clearsprings (asylum seekers)
Under one roof (services for drug misuse/homeless)
Social housing
Where there is care for long term neurological conditions
Services dealing with obesity
Health trainers; core role includes assisting a person with initial access to a
dentist and an offer to accompany a person to their first appointment.
It was questioned whether there was secondary prevention input after a child
had had a general anaesthetic for tooth extraction.
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Oral Dental Health Needs Assessment for NHS Norfolk
•
•
•
Substitute prescribing, e.g. shared care: sugar free methadone
Prison health services
Older people with malnutrition (particularly in care homes): an
imminent/current initiative.
Summary Points - Section 4
Prevention services
•
There is natural fluoride in Norfolk water supplies, but at a lower than optimal
level to prevent tooth decay, a problem which is a greater risk for vulnerable
groups
•
School dental screening services are not the most efficient way to improve
dental health, but can be most beneficial in special schools or schools serving
pupils of highest need.
•
The dental check up is included in the Marmot Review on health inequality as
a preventive service. Dental check ups are delivered in Norfolk chiefly
through the dental contract as one UDA and the target is that 63% of the NHS
Norfolk population accesses this service at least once in 24 months, up from
the current uptake of just under 60%. NHS Norfolk is working with providers
to ensure that frequency of check ups for any individual is decided in line with
NICE guidance.
•
Evidence based oral health promotion services are beneficial and cost
effective if directed appropriately to particular population groups.
Collaborative work between the specialised dental oral health promotion
team, consultant in dental public health and leaders of other services is
recommended, including better, consistent information on self care and
services that include regular professional application of fluoride varnish, by
dentists or specifically trained members of a dental team.
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Part 2: Dental Care Pathways, services in Norfolk, gaps,
efficiencies and productivity
Section 5: Dental Care Pathways
5.1 Overview of system
Professor Steele, in his independent review of NHS dental services in England (July
2009), presents a ‘clear view of what NHS dentistry should offer’:
A lifetime-focused, evidence-based oral health service, which aims:
•
•
•
To prevent oral disease and the damage it causes
To minimise the impact of oral disease on your health, when it occurs
To maintain and restore quality of life when this is affected by the condition of
your mouth’.
Professor Steele states that there should be clarity and consistency to what NHS
dentistry can and should offer to patients and outlines these in a diagram based on a
pyramid, reproduced below (Figure 24). Towards the base are things he describes
as ‘at the heart of any dental system’ and at the top are ‘advanced and expensive
services’ which should be considered if public resources stretch that far. Hence
resource would be invested properly in health, with a long term oral health goal. The
various levels can be ordered into a simple pathway so that patients and dentists can
see where and how the different elements are offered.
Figure 24: Priorities for investment in oral health (Steele 2009)
Advanced and
complex care
Continuing care
High quality routine
treatment of dental
Reducing
priority for
public
investment
Personalised disease
prevention
Urgent care
and pain relief
Public health
The argument for each of these layers is considered in the table that follows (Table
13), with a comment on potential impact on secondary care service costs.
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Oral Dental Health Needs Assessment for NHS Norfolk
Priorities for public
investment
Public Health
Steele rationale
Comments
Strong, co coordinated
system, recognising
common risks and
providing support to
profession and info to
patients on how to
minimise risks
Urgent care
Quick, definitive pain
relief to anyone who
needs it; relatively
inexpensive
Personalised
disease prevention
High priority for
investment at individual
level as failure results
in cavity or periodontal
pockets that are
irreversible damage,
with lifetime
consequences and
costs
Routine treatment
and continuing care
Quality primary care
and continuing card as
oral health is a lifetime
concept
Advanced, complex
and expensive
treatments
Offered for quality of
life rather than disease
management; not an
automatic right for
everyone but targeted
to where risks are
managed and where
need and benefits
greatest.
Strong evidence of association between
prevalence of oral cancers (expensive
to treat in secondary care) and smoking
and alcohol use. Traumatic facial injury
can result from violence/accidents
related to alcohol misuse.
Smoking exacerbates periodontal
disease hence risk of tooth loss. Links
between sugars in diet and tooth decay.
Delaying seeking help for dental pain
can result in severe dental infections
that may need admission. This
happens quite rarely, but is reported to
be on the increase. Population groups
who do not use current services
regularly, with poorer dental health are
more likely to need services for urgent
care and ultimately secondary care for
complex oral surgery that might arise.
A large population group will benefit;
rectifying where prevention fails, and
where restorations don’t last is currently
the majority of work in primary care.
The current impact on secondary care
is where need arises for difficult oral
surgery or more complex restorative
work although the latter is not routinely
provided at specialist level or in
secondary care.
A large population group already
benefits and there would be high
demand for specialist care if it was
available. Currently there is an advice
only service re complex restorative care
provided in secondary care setting in
Norfolk, mainly to support dentists’
treatment planning.
For secondary care this includes dental
implants for e.g. severe facial deformity
or facial reconstruction after a major
accident or following cancer surgery.
Implant surgery is becoming more
available in primary care, but it is not
funded by the NHS.
Table 13 Priorities for investment in oral health and their impact on secondary care
service costs
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5.2 Current pathways for dental care in Norfolk:
For most people, a visit to a dentist (General Dental Practitioner, GDP) is all that
needs to happen to allow access to all the care and treatment required. At the end of
the course of treatment, the GDP will advise when the next check up should be,
which may be between 3 months and two years depending on the patient’s need.
Referrals might occur in the following circumstances:
• A child assessed to have orthodontic needs, to an orthodontic service, which
may be secondary or primary care based, provided by a consultant, specialist
or dentist with a special interest. There is a PCT referral management
service.
• An adult with severe dental anxiety, that cannot be managed at the chairside,
to a sedation service
• A child with high treatment need and behavioural management issues, to the
salaried dental service where as a last resort, a hospital based general
anaesthetic can be given.
• An adult requiring extractions that are technically difficult to an oral surgery
service which may be secondary or primary care based, provided by a
consultant, specialist or dentist with a special interest. There is a PCT referral
management service.
• A person with complex treatment needs, to a secondary care based
restorative consultant for an opinion and treatment plan to assist the general
dentist.
• A person with complex management needs, for example due to severe
learning disability, to the salaried dental service.
Section 1.3 below provides data on the various services and approximate resource in
each sector of dentistry in Norfolk, excluding the spend on primary care based oral
surgery:
5.3 Overall spend
Area of spend
Approx annual
amount
27,856 000*
83
Oral surgery service in primary care
500 000
1
Secondary care:
Acute outpatients
Daycases/Inpatients
(09/10)
Salaried community services (09/10)
Community dental service
Access
2,265,961
7
General dental services (10/11 prices)
including orthodontic, sedation, some domiciliary
care, out of hours and prison
%
10
Total (approx)
2,005,800
1,252,100
6
3
33,380,361
100
*Also there is revenue from patient charges of £11,191m
It is clear that the majority of spend is in general dental services.
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Summary points - Section 5
•
•
Professor Steele, in his independent review of dentistry in 2009, provided a
priority framework for public investment in oral health. Fundamental was
urgent care and pain relief, followed by personalised disease prevention, high
quality routine treatment of dental disease, continuing care and lastly,
advanced and complex care.
Most (83%) dental prevention and treatment takes place through general
dental services, supported by some specialised areas on referral. The
second largest, 10% is services provided by the salaried provider that caters
for more vulnerable clients and specialised areas of care.
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Oral Dental Health Needs Assessment for NHS Norfolk
Section 6: Current Service Provision
By Rachel Field
6.1
General Dental Services
A new dental contract was introduced in England and Wales on` 1st April 2006,
bringing a fundamental reform of the remuneration system. Under the new contract,
dentists are paid an agreed annual contract, on the basis of completed courses of
treatment. Each course of treatment is allocated a number of units of dental activity
(UDA) which dentists accumulate to meet the terms of their contract.
Courses of treatment are classified into treatment bands according to their
complexity. Each band has an associated number of UDA’s and a patient charge.
As at April 2010 the treatment bands and associated charges are:
Treatment
Band
Band One
Band Two
Band Three
Treatment included
Covers examination, diagnosis,
advice and a scale and polish if
needed.
Covers everything within B1, plus
further treatments such as fillings,
extractions and RCT work
Covers everything within B1 and B2,
plus crowns, dentures or bridges.
Urgent
Cost to
patient
£16.50
Number of
UDA’s
1
£45.60
3
£198.00
12
£16.50
1.2
The new contract also altered the remuneration for orthodontic services, with the
allocation of Units of Orthodontic activity (UOA’s) to assessments (1 UOA) and case
starts (21 UOA’s).
Domiciliary and sedation services are also contracted up to an agreed annual
contractual level.
6.2 Details the contracts currently in operation in NHS Norfolk area for all aspects of
dental services. It also looks at current access and activity levels, patient satisfaction
and the types of treatment being performed.
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6.2
Local General Dental services provision – current contracts
Current contracts
As at June 2010, NHS Norfolk had 98 contracts with 82 providers, for general dental
services. The total UDA’s commissioned from these contracts as at June 2010 was
1,290,364.
Contracts are held by a mixture of corporate bodies, partnerships and individuals.
The majority are GDS contracts; however there are also 4 PDS and 5 PDS plus
contracts held. Baseline contract value for general dental services is approx £32.3m
Contract size varies greatly, from smallest at 220 UDA’s (child only contract), to the
largest of 52,975. UDA values also differ, ranging from £17.47 to £35.32, with an
average of approx £23.85.
Location of general dental services
The map on the next page details the location of all general dental practices. The
provision in the main Norfolk towns and Norwich is as follows:
•
Norwich: 415,000 UDA’s split over 31 practices
•
Kings Lynn: 130,000 UDA’s split over six practices
•
Thetford: 45,500 UDA’s provided by one practice
•
Wymondham: 49,000 UDA’s split over three practices
•
Attleborough: 28,000 UDA’s split over two practices (three providers)
•
Dereham: 47,500 UDA’s split over two practices (three providers)
•
Diss: 33,800 UDA’s split over three practices (four providers)
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Figure 25: Map showing location of practices and their locations in Norfolk
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Oral Dental Health Needs Assessment for NHS Norfolk
Activity undertaken by current providers
Data from the BSA 2009/2010 vital signs report shows the following:
Access trends: Access rates for NHS dentistry are measured using a 24 month
rolling period. As at March 2010, the access rate for Norfolk based on a population
estimate of 756,400 was 57.28%. This represents a small drop from access rates in
2006, which were 59%.
Figure 25: Access trend analysis for Norfolk – source BSA vital signs
Investment in additional dental activity and new providers has led to access rates
increasing. The table below illustrates the change in patient numbers between June
2009 and June 2010, with an increase of 11,376 patients.
Table 14: Demonstrating the changes in dental patient numbers from June
2009 – June 2010
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6.3
Local Orthodontic service provision – current contracts
The new contract introduced in 2006 also altered the remuneration for orthodontic
services, with the allocation of Units of Orthodontic activity (UOA’s) to assessments
(1 UOA) and case starts (21 UOA’s).
Since 2008, NHS Norfolk has operated a referral management centre for
orthodontics. Dentists are asked to refer directly to this centre, to allow effective
monitoring of the numbers of referrals and avoid past problems encountered with
long waiting lists and back logs. The management of waiting lists is especially
important as orthodontic provision falls under the guidelines of 18 week referral to
treatment time (Department of Health target).
Contracted activity
Orthodontic services in a primary care setting are predominately based in Norwich.
The table below shows the UOA’s currently contracted by location, with the map on
the next page showing the location of practices.
Table 15: Orthodontic UOA’s by location within Norfolk
Norwich (4 providers)
Swaffham
Thorpe
Acle
Long Stratton
Watton
Harleston
Loddon
Attleborough
Wymondham
Costessey
Kings Lynn
Roydon
Cromer
UOA
30,706
215
2,750
1,050
53
518
383
579
460
1,980
1,430
304
709
3,948
TOTAL
45,085
63% of UOA’s currently commissioned are undertaken by dentists who restrict their
practice entirely to orthodontics, with the remainder being undertaken by general
dentistry providers who retain an interest in orthodontics. It is not clear whether or
not this spread of providers is appropriate or meeting the demands of patients needs.
There is provision for orthodontic treatment within a hospital setting, both at Queen
Elizabeth NHS Trust in Kings Lynn, and at the Norfolk and Norwich University
Hospital in Norwich.
63
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Oral Dental Health Needs Assessment for NHS Norfolk
Figure 26: Orthodontic contracts in NHS Norfolk
64
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Oral Dental Health Needs Assessment for NHS Norfolk
Activity undertaken by current providers
The statistics below are taken from the June 2010 Vital Signs report produced by the
BSA. It shows NHS Norfolk has a slightly higher rate of assess and reviews occurring
when compared to the national average, which may be linked to patients being
referred too early historically as practitioners were concerned about waiting times.
Alternatively non specialist providers may only be assessing and referring on patients
to a specialist. It could be argued that this does not represent best use of resources.
The extra funding put into orthodontics has removed this backlog and therefore it
would be hoped that assessments are only carried out at appropriate ages.
Table 16: Rates of Access and Reviews – source BSA Vital Signs
Levels of referrals
The total number of orthodontic referrals received through the RMC in 2009/10 was
2,481.
The Vital signs report for 2009/2010 gave the following data for orthodontic activity:
Patients seen for assessment that resulted in a case start: 2,281
Patients seen for assessment that were refused treatment: 763
Patients seen for assessment that were put on review:
3,266
Patients where treatment was completed in 09/10:
1,127
Patients where treatment was abandoned/discontinued in: 97
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Oral Dental Health Needs Assessment for NHS Norfolk
6.4
Local Sedation services provision – current contracts
The main sedation provider is based in the centre of Norwich. The current contract is
for 3,018 sedations per annum. Dental practitioners refer directly to the practice. As
at September 2010, the practice had a significant waiting time for treatment of
approximately six months.
There are a further three sedation providers with smaller contracts totalling 250
sedations per annum, all of which are located within the Norwich area.
Neighbouring PCT’s refer into the main sedation provider, as there are no equivalent
services in the areas of Suffolk, Great Yarmouth and Waveney and Lincolnshire.
Figure 27: Map showing sedation service provision in Norfolk
Sedations performed in 2009/2010 totalled 3,761, with 3,003 of these being
performed by the main provider.
6.5 Local Domiciliary services provision – current contracts
The majority of domiciliary dental care is currently provided by one contractor. This is
contracted via an enhanced UDA value, with an activity level of 3,795 UDA’s. Four
other providers are contracted for a very small amount of domiciliary activity,
equating to 63 UDA’s.
Contractually the main domiciliary provider must cover domiciliary visits within a ten
mile radius of Norwich. However, over the last two years extra activity has been
awarded to the provider and therefore they have extended this to a 40 mile radius
and hence cover most of NHS Norfolk. This activity was temporary and has not been
agreed as a permanent contract variation.
There are currently no domiciliary providers covering the areas further than 40 miles
from Norwich.
During 2009/2010 there were 1,012 patients treated via domiciliary care.
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Oral Dental Health Needs Assessment for NHS Norfolk
6.6 Local Access services provision – current contracts
The changes to the contract in 2006 meant that patients are no longer registered with
a dental practice and responsibilities for urgent treatment were therefore only
maintained by the dentist when the patient was in an open course of treatment.
Therefore, NHSN also contracts a number of urgent access facilities across the
county. These are centred on two access centres (Kings Lynn and Norwich), with
other practices providing access sessions/slots.
Kings Lynn Dental Access Centre: Based on Kings Street in Kings Lynn, this
centre is open from 8am till 7pm, Monday to Friday. Patients can self refer to this
centre or be signposted by another dental practice, health professional or PALS.
Siskin Dental Centre: Based at Norwich Community hospital in Bowthorpe, this
centre is open from 9am till 5.30 pm, Monday to Friday. Again patients can self refer
or be signposted to the centre.
Practice based access slots: There are five practices with access slots which are
accessed through the PALs Service.
Numbers of patients being seen at access slots:
Data from NCH&C recently received: (there has been no validation of this data)
Siskin Centre:
DAC, Kings Lynn:
Average of 577 patients per month
Average of 815 patients per month
6.7 Local special care services provision – current contracts
Special care dentistry services are provided by NCH&C. The service is aimed at
those patients who by nature of their complex needs have been unable to access
general dental services. Examples of groups of patients accessing this service are:
•
•
•
•
•
•
•
Adults and children with complex or special needs, including learning
difficulties, where treatment with a general dentist has not been possible;
Children with behaviour or management problems which make them
unsuitable for treatment within general dental services;
In-patients of Norfolk and Waveney Mental Healthcare Trust, where treatment
with a general dentist has not been possible;
Those who are housebound and require domiciliary care not available from
general dental services;
Adults and children who are medically compromised and require the provision
of primary care dentistry in a hospital setting;
Adults with Learning Difficulties and children who have been assessed by the
service as requiring treatment under general anaesthesia and
Orthodontic services for patients who are unsuitable for treatment in a
specialist orthodontic or hospital setting.
Services are predominately provided from the Siskin Centre at Norwich Community
Hospital, with a number of satellite clinics and use of acute care facilities for general
anaesthetic cases.
The map below shows the location of the premises used.
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Oral Dental Health Needs Assessment for NHS Norfolk
Figure 28: Map showing locations of special service provision in Norfolk
Numbers of patients being seen/sessions being provided
Data from NCH&C recently received: (there has been no validation of this data)
Location
Full staff
complement
Average
Session/wk
Siskin
54
Special
44
Care 28 Access
Special Care 17.5
26 Access
25.5
4
6
6.5
9
1
1
2
1
4
0.5
4
3
6
2
- 4
3
4
8
8
4
3
Access only
33 Access only
33
over 7days
over 7 days
7
6
4
4
3
2
Thorpe
Bowthorpe
Norvic
N Walsham
Dereham
Attleborough
Sheringham
Hoveton
Swaffham
Downham Mkt
St James, KL
Terrington
Hunstanton
King’s St KL
HMP Wayland
HMP Norwich
HMP Bure
Total
Current
Average
Sessions/wk
147
Current Activity
Patients appts
Average/month
935
358
577
79
112
23
21
13
72
46
44
146
30
815
198
74
80
121
68
2,688
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Oral Dental Health Needs Assessment for NHS Norfolk
Summary points – Section 6
Current service provision, general dental services
• Patients understand three bands of treatment for primary care dentistry, which
attract a charge unless the patient is exempted, which includes all children. The
dentist delivers the contract to the PCT usually in a currency of UDAs.
• There are 98 contracts with 82 providers, delivering 1,290,364 UDAs with a
baseline contract value of £32.3M, the average UDA rate being £23.85.
• Services have been mapped, to assess access across the county and distribution
of spread, particularly in relation to market towns and roads
• Access rates to NHS primary care dental services in Norfolk over 24 months are
57.28% and the positive impact on this figure, due to new providers from recent
commissioning and investment is still being realised.
Orthodontics
• Measure of orthodontic activity is the UOA; a case start attracts 21, and
assessment, 1.
• Referrals into the service are now centralised through a referral management
service which enables monitoring, evaluation and equitable services for patients.
• For historical reasons, most services are in Norwich, and there are many small
contracts scattered between providers of general dental services.
• Some orthodontic services are provided in hospitals, via out patients, this is
particularly important for access in West Norfolk.
• Norfolk patients were receiving higher rates of assessment and review, relative to
other areas of the country. There was a backlog of cases waiting to start
treatment and in 2009/10, 2,481 patient referrals were received to the referral
management service.
• It is not clear whether current spread of orthodontic provision meets patient’s
needs and is good vfm.
Sedation
• The main provider of sedation services is a single practice in Norwich that
provides 3,018 sedations, on direct referral.
• Waiting times are long, with many patients referred from neighbouring PCT areas.
Domiciliary services:
• Mainly a single provider in general dental services. 3,858 UDAs per year, with
1,012 patients treated in 2009/10
Local access provision
• Urgent access (during normal clinical hours) is provided at Kings Lynn and
Norwich, which between them see about 1,390 patients per month. In addition,
other practices provide some slots or sessions.
• Some of the sessions can be accessed only on enquiry to the NHS Norfolk PALS
service.
Special care services
• Special care dentistry is more appropriate for some individuals, usually from
vulnerable groups. Most services are in Norwich and Kings Lynn but there are a
number of part time clinics around the county.
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Oral Dental Health Needs Assessment for NHS Norfolk
Section 7: Secondary care & referral Management
7.1 Hospital out patients (all secondary care data in this section needs to be
verified)
For the year 2009/10, the total spend on outpatients for the oral and dental
specialties including orthodontics was £2,265,961, on a total activity of 25,916
contacts. This covers all Norfolk residents over a very wide range of hospitals across
the country. Many of the visits distant from Norfolk were isolated ones, suggesting
that the person was on a visit to a different part of the country when experiencing a
problem.
The following table is a selection of 13 different hospitals where the numbers of
attendances were greater.
Table 17: Comparative Secondary Care Referrals
Hospital
1
2
3
4
5
6
7
8
9
10
11
12
13
Oral Surgery
contacts
Barts and London
Bedford
Cambridge
East Kent
Guys
Ipswich
James Paget
Kings
Norfolk & Norwich University Hospital
Peterborough
QE
UCL
West Suffolk
Orthodontic
contacts
12
23
5
121
11
14
130
149
6
4,904
62
1,986
15
79
OMFS 287/OS 27
3
20
156
325
19
12,390
189
4,213
28 OMFS/15 OS
472
(OMFS = Oral and Maxillofacial surgery; OS= Oral Surgery)
A single orthodontic outpatient appointment can attract a charge of around £182.
The contacts included on the table above cost £2.23M
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Oral Dental Health Needs Assessment for NHS Norfolk
7.2 Daycases (emergency and elective)
Between Norfolk and Norwich University Hospital (NNUH) and the Queen Elizabeth
(QE) there were 4,136 procedures undertaken, at a cost of
£2,906,735, the overwhelming majority being oral surgery, most of which are elective
day cases.
Each of the hospitals is considered separately below:
Queen Elizabeth Hospital:
There were 1465 procedures, priced at £850 442, 2009/10 prices. Picking out cases
that were limited to dental rather than soft tissue or more complex surgery, the
following table shows that 1165 (80%) of these procedures (£659 532) fell within
these categories:
Table 18: Secondary care QEH activity data – selected procedures 2009/10.
Procedure
1
2
3
4
5
6
7
8
9
10
11
12
Number done
Surgical exposure of tooth
Surgically impacted tooth
Surgically impacted wisdom tooth
Surgical removal of retained tooth
Surgical removal of tooth
Surgical removal of wisdom tooth
Single tooth extraction
Surgical removal of tooth
Upper clearance
Extraction of multiple teeth
Full clearance
Lower dental clearance
Total
Cost £
8
30
136
151
100
105
354
5
4
252
20
5
1,165
4,824
18,459
80,992
98,297
67,254
64,723
135,865
3,236
2,436
169,150
13,296
3 666
659,532
Norfolk and Norwich University Hospital
Total NNUH activity was 2,671 procedures, priced at £2,056,293. The data on
selected procedures below cover 39% of all procedures and 34% costs.
Table 19: Secondary care NNUH Activity data 2009/10
Procedure
Apicectomy
Extraction, multiple teeth
Clearance
Lower clearance
Other tooth
Surgical exposure of tooth
Surgical removal of impacted tooth
Surgical removal of impacted
wisdom tooth
9
Surgical removal; retained root
10 Surgical removal tooth
11 Surgical removal wisdom tooth
12 Upper Clearance
Total
1
2
3
4
5
6
7
8
71
Number done
17
184
38
5
5
49
80
287
Cost £
10,900
134,914
29,593
3,192
2,455
35,267
56,928
174,963
88
135
140
11
1,039
56,685
96,434
89,724
8,119
699,174
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Oral Dental Health Needs Assessment for NHS Norfolk
7.3 Referral management
Orthodontics
In the year 2009/10, the total number of orthodontic referrals received through the
RMS for 2009/10 was 2481. Of the 2481 received 1106 had an assessment 451
went on to have a brace fitted. It is expected to find a ratio of assessments to case
starts of about 2:1. In Norfolk in the previous year, NHSN was working to clear a
backlog of waiting cases. Further work is underway to clarify capacity and patient
flows, and to improve quality monitoring of referrals.
The following graph shows referrals by age of patient in 2009/10
Figure 28: Orthodontic referrals by age 2009/10
Orthodontic referrals by Age 2009/10
600
No of referrals received
500
400
300
200
100
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Age of Patients
Oral surgery referrals
NHS Norfolk has contracts with a number of specialist providers of minor oral surgery
services to ease the load on the acute trust and referral pathways have been
consolidated with the Trust. Between April and July 2010, 1,301 referrals were
received and triaged by the dental adviser. 451 were passed to the hospital and the
remainder shared between the specialist providers. Projected expenditure on the
primary care element for the current year, based on current referral rate and division
between hospital and specialist is £514,000.
Referrals are increasingly closely scrutinised and NHSN is working with dentists who
refer more frequently.
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Oral Dental Health Needs Assessment for NHS Norfolk
Section 8: Public Voice
By Wendy Napier
8.1 National Surveys
Dentistry Watch
In 2007, the Commission for Patient and public involvement in Health conducted a
national survey to find out what patients really think about NHS dental services.
Members from local Patient and Public Information Forums asked a total of 5,212
patients for their views on crucial issues regarding dental services across the country
between July and September 2007. The resulting Dentistry Watch report was
published in October 2007liv.
The main findings of this survey were as follows:liv
93% of NHS patients are happy with the treatment they receive.
Almost a fifth of patients have gone without treatment because of the cost.
Almost half of all NHS patients do not understand NHS dental charges.
78% of patients using private dental services are doing so because either their
dentist stopped treating NHS patients (49%), or because they could not find an
NHS dentist (29%).
35% of those not currently using dental services stated it is because there is not
an NHS dentist near where they live.
Citizen’s Advice Bureau Survey
The Department of Health recommends that people searching for an NHS dentist
should contact either their PCT or NHS Direct. A recent report from the Citizen’s
Advice Bureau, however, suggests that these search strategies are not well used
(see Figure 29).lv In the East of England, for example, around 63% of patients heard
about their current dentist from friends and family and around 42% do not know how
to get emergency treatment outside office hours (Dentistry Watch Report, 2007).
This means that even where services are available, people may not be able to
access them.
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Oral Dental Health Needs Assessment for NHS Norfolk
Figure 29: Citizen’s Advice Bureau Data on How People Go About
Finding an NHS Dentist
Source:
CAB Evidence Briefing Gaps to fill. CAB evidence on the first year of the NHS
dentistry reforms. March 2007 Available at URL:
http://www.citizensadvice.org.uk/pdf_gaps_to_fill.pdf
The CAB found that 65% of people who were unable to find an NHS dentist simply
went without treatment (see Figure 30)
Figure 30: The Course of Action Taken by Respondents if Citizens Advice
Bureau Survey Who Were Unable to Find an NHS Dentist
Source: CAB Evidence Briefing Gaps to fill. CAB evidence on the first year of the NHS
dentistry reforms. March 2007 Available at URL:
http://www.citizensadvice.org.uk/pdf_gaps_to_fill.pdf
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Oral Dental Health Needs Assessment for NHS Norfolk
Omnibus Survey
The Omnibus survey gathered data about the impact of oral problems on the quality
of life of adults. A population representative sample of 2,507 adults across the UK
was briefly interviewed on oral health related quality of life. The results were
analysed by the Dental Observatory.
The main findings of this survey were as follows:lvi
7% of adults in England and 5% of adults in the East of England, experience
‘painful aching in the mouth fairly or very often’. The figures for men and
women are equal.
Experience of painful aching in the mouth varied little between countries.
As age of respondents increased, there was a general reduction of reported
painful aching.
The prevalence of painful aching ‘fairly or very often’ and experience of oral
problems compare closely with the values arising from the Adult Dental
Health Survey 1998. This finding suggests that this parameter varies little
over time.
Patients Association Report
The Patients Association published their report, The New Dental Contract - Full of
Holes and Causing Pain, on the new dental contract in March 2008.
The report is based on the Association’s recent survey of PCTs (although they are
unspecific about their methodology). Their main findings of the report were as
follows:lvii
The NHS dentistry service provided by PCTs varies from PCT to PCT creating a
‘postcode lottery’.
Patients are confused about how to access dental services in their locality.
Patients are at risk of inadequate care because ‘UDAs, rather than patient need
are being funded’.
Prevention of oral disease is at risk under the new contracting system.
GP survey Quarter 4: 2009-2010 –Questions regarding Dentistry in Norfolk
The GP Patient Survey is a quarterly survey of GP adult patients, which is managed
by Ipsos MORI on behalf of the Department of Health. The main results of the latest
Survey for 2009/10 Q4 were published in June 2010. For the first time, for 2009/10
Quarter 4 (January to March), dental questions were included in the Survey.
About 400,000 adults were asked to complete questions about access to NHS
dentistry in the previous 2 years. Participants in the Survey were asked if they had
tried to obtain an appointment with an NHS dentist, and if so, what was the type of
their appointment and had they been successful in obtaining an appointment.
Patients who had not tried to obtain an NHS dentist in the previous 2 years were
asked to select one reason why they had not tried.
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Oral Dental Health Needs Assessment for NHS Norfolk
Main results:
•
•
•
•
•
•
•
•
•
•
•
31% of NHS Norfolk respondents reported they have stayed with their dentist
when they went private.
147,600 completed dental question forms were received, of 400,000 that
were distributed (response rate of 37%). Results are available at National
(England), Strategic Health Authority (SHA) and Primary Care Trust (PCT)
level;
59% of adults in the survey had tried to obtain an appointment with an NHS
dentist in the 2 year period before March 2010.
92% of respondents who had tried to obtain an appointment within the past 2
years were successful, 8% were unsuccessful. These percentages excluded
those who could not remember their outcome.
Respondents who had tried more recently were more successful. 95% of
respondents trying within the past three or six months were successful.
For 78% of adults the last appointment sought was for routine dentistry; 18%
were seeking an urgent appointment and 2% didn’t remember the type of
appointment they had requested.
81% of the most recent appointments sought were with the dental practice the
patient had previously attended. In these cases the successful percentage
was 95%.
North East SHA had the largest percentage of the adult population seeking an
NHS dental appointment in the last 2 years, at 66%, whilst South Central SHA
had the smallest, where 52% sought an NHS appointment.
Success in getting an appointment North East SHA had the largest
percentage, with 95%, compared to South Central SHA with the smallest
(90%).
Adults who have not tried to get an NHS appointment in the last 2 years: 41%
of respondents did not try to get an appointment with an NHS dentist in the
last 2 years.
The most frequent reason for not trying to get an NHS dental appointment in
the previous 2 years was, 'I stayed with my dentist when they moved from
NHS to private' and this was mentioned by 21% of adults. The next most
frequent reason was, 'I didn’t think I could get an NHS dental appointment', by
18% of responses.
The results below compare NHS Norfolk results from this survey with England as a
whole, the East of England SHA average and with NHS Devon (as a comparator trust
to NHS Norfolk).
It should be noted that Norfolk respondents were:
o
o
o
o
o
All 18 years or older, 54% above 55 years, 4% between 18-24 and a total of
12% 34 years and younger.
44% male, 56% female.
47% in paid employment, either full or part time, 36% retired, 3%
unemployed, 1%in full time education, 6% looking after the home.
98% reported their ethnicity as white.
All results in this section are given as a percentage and are not weighted.
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Oral Dental Health Needs Assessment for NHS Norfolk
Results
Question 1: When did you last try to get an NHS Dental Appointment for
yourself?
In last 3
months
England
EoE SHA
NHS Norfolk
NHS Devon
Between
3-6
months
16
16
18
16
23
24
25
26
Between
6-12
months
12
12
14
12
Between
1-2 years
More than
2 years
Never
8
8
7
7
18
19
17
22
23
19
19
18
Question 2: For those who responded that they had tried to get an
appointment were asked if they were successful in getting an NHS Dental
appointment?
England
EoE SHA
NHS Norfolk
NHS Devon
Yes
91
93
92
92
No
7
6
7
7
Can’t remember
2
1
1
1
It appears that 57% of Norfolk respondents accessed NHS dental practices within the
past 12 months, slightly higher than the average for the EoE SHA and Devon (52,
and 54% respectively).
The overall success rate was 92% - comparable with England, EoE and NHS Devon.
Question 3: When you last tried to get an appointment what type of
appointment were you trying to get?
England
EoE SHA
NHS
Norfolk
NHS Devon
Routine check
up/not urgent
76
78
80
77
Urgent
Treatment
18
17
17
Other
19
Can’t remember
4
3
2
1
1
1
3
1
For all four sectors routine checks and non-urgent appointments predominated in the
type of appointments required.
Question 4: Last time you tried to get an NHS Dental appointment, was it with a
dental practice you has been to before for NHS Dental care?
England
EoE SHA
NHS Norfolk
NHS Devon
Yes
82
85
87
79
No
14
13
12
19
77
Can’t remember
3
2
2
2
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Oral Dental Health Needs Assessment for NHS Norfolk
With 87% NHS Norfolk respondents stating that their last appointment (attempted
appointment) was with a practice they has previously used we can surmise that the
majority of the respondents were satisfied with their previous experience or felt they
had no alternative. This would appear to be positive for continuity of care.
Question 5: For those that responded that they had not tried to get an
appointment in the last 2 years with a NHS dentist were asked why this was.
England
EoE SHA
NHS
Norfolk
NHS
Devon
Not
needed
to visit
I have
no
natural
teeth
Not had
time to
visit
18
17
12
10
2
2
13
13
11
10
Don’t
like
going
Didn’t
think I
could
get an
NHS
Dentist
I am on
a
waiting
list for
an NHS
dentist
I stayed
with my
NHS
dentist
when
they
went
private
I prefer
to go to
a
private
dentist
NHS
dental
care is
too
expensi
ve
Anot
her
reaso
ns
7
8
16
14
1
*
21
23
15
16
3
4
7
7
1
7
11
0
31
12
3
8
1
4
16
1
32
17
1
5
•
31% of NHS Norfolk respondents reported that they have stayed with their
dentist when they went private, with another 12% preferring to go private.
These figures should inform and influence any access targets set for NHS
Norfolk
•
A tenth of respondents still thought they could not get an NHS dentist –
although this is lower than other sectors compared this still needs to be
addressed.
•
It is of concern that 13% of respondents felt there was no need to have dental
checks up when they had lost all their natural teeth. This could increase the
risk of delayed diagnosis of oral cancer and any effects of ill fitting dentures. It
is recommended that this patient group is reviewed at least once every 2
years.
•
The 13% of respondents reporting that they felt no need to visit a dentist
implies that this group would only visit once symptoms arose. This group are
again at increased risk of delayed diagnosis of oral cancers, preventable pain
and possible tooth loss.
8.2 Regional surveys
East of England Attitude to Health Surveys
This is a regional survey commissioned from IPSOS MORI by EoE SHA. The survey
covers many healthcare services with a specific section on dentistry. Following the
analysis of the survey the PCTs within the EoE SHA were ranked against each other.
The latest survey (Wave 3) was carried out between August and September 2009
and involved 403 interviews of randomly selected Norfolk residents. These results
were compared with those obtained a year earlier (Wave 1) which were carried out
on 401Norfolk residents. Wave 3 results are given in the tables below.
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Oral Dental Health Needs Assessment for NHS Norfolk
Question 1
Have you visited a dentist in the past 24 months?
Yes
NHS
Yes
private
No
Yes
NHS
Wave 1
Net score
Improvement
on Wave 1
61
25
14
59
+2
SHA
SHA
Ranking Ranking
Wave 3
Wave 1
out of 14 out of 14
1
1
Comment
Within SHA
average
Questions 2-7: Patient satisfaction with NHS dental practice on cleanliness,
access, and wait for routine appointment, flexibility of the appointment system
and explanation of charges.
Satisfied
Cleanliness
98
+1
SHA
Ranking
Wave 3 out
of 14
8
Transport facilities
and access
74
+3
7
8
91
+5
12
12
80
-9
13
7
78
-8
13
8
76
+3
9
8
Acceptability of
distant to NHS
Dental practice
Wait for routine
appointment
Flexibility of
appointment
system
Explanation of
NHS charges
Net score
Improvement
on Wave 1
SHA
Ranking
Wave 1 out
of 14
12
Comment
Improvedwithin SHA
average
Improvedwithin SHA
average
No change within SHA
average
Worsened now below
NHS
average.
Worsened now below
NHS
average.
Improvedwithin SHA
average
Question 8: Likelihood of using NHS dentist
Yes
70
No
30
Net score
Improvement
on Wave 1
+3
SHA
Ranking
Wave 3
out of 14
11
79
SHA
Ranking
Wave 1
out of 14
11
Comment
Within SHA average
.
Oral Dental Health Needs Assessment for NHS Norfolk
Question 9: Top 6 reasons for choosing private dental care
Reason
Existing dentist went private
Location/transport/parking
Better cleanliness/quality of care/
No NHS dentist available /easier to find a
private dentist
Waiting time to be seen better also better
appointments
No choice/only one available/no other
option
Score
%
17
17
16
Net score change
on Wave 1
-7
-3
+1
20
-5
11
7
-2
-5
Question 10: Top 6 factors that would encourage patients to go to an NHS
dentist
Reason
Better value for money
Location/transport/parking
Availability/ able register locally /
Waiting time/appointments seen to be
better
Better cleanliness and quality of care
Nothing/would never use NHS again
Score
%
21
20
15
12
Net score change
on Wave 1
+7
+3
0
-1
8
7
-2
0
Overall conclusion: Satisfaction with dentistry within NHS Norfolk remains
stable
There have been no significant changes in satisfaction with dentistry in NHS
Norfolk.
NHS Norfolk remains at the top for levels of usage of dentists.
While both remain stable, satisfaction with wait for appointments and flexibility of
appointments is below the SHA average.
NHS Norfolk has fallen more than 5 places in the rankings, to the bottom 2, on
both these measures.
Further to this, NHS Norfolk is in the bottom 5 of the rankings for acceptability of
distance to travel and likelihood of using NHS dentists, though still in line with the
SHA average.
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Oral Dental Health Needs Assessment for NHS Norfolk
8.3 Local Surveys
Access to Dental Services: Dental care in Norfolk
This survey was commissioned by NHS Norfolk and conducted by Ipsos MORI Social
Research Institute to understand local residents’ views of dental services in the
Norfolk area and covered three broad themes:
• Usage of dental services – the extent to which residents use local dental
services, including reasons for not using services and reasons for choosing a
particular dentist.
• Satisfaction with current services and priorities for improvement – how
satisfied residents are with the current dental services they receive, and where they
see the priorities for future spending within their local dental services
• Children’s services – usage of, and satisfaction with, dental services for children
in the area.
The study collected and analysed both qualitative and quantitative information.
Users;
• Eight in ten of Norfolk’s residents had visited a dentist in the last year
• Only 1% said they had never visited the dentist.
• Over two-thirds have been to the dentist within the last six months.
• There was also difference in usage by demographic groups in those more
likely to attend i.e.
a) Women more than men
b) Older more than younger.
c) Those from higher social grades
d) Non-working more than those in employment perhaps indicating that more
conveniently placed dental practices near major areas of business in the
Norfolk area could further increase usage.
• Parents reported having children to be an important factor in their own
attendance at the dentist, setting a good example to their children.
• The Polish group respondents all reported they had access to private dental
care in Poland and some reported they had tended to avoid British dentists as
they had experienced difficulties in accessing an NHS dentist in their local area.
• All of the above is encouraging and indicates that the majority of residents
were well aware of the need to safeguard their dental health and were prepared
to do this regularly.
Non users: Those who have not been to the dentist in the last year were asked
specifically why?
•
•
•
•
•
20% stated that they could not find an NHS dentist, indicating some access
issues that need to be addressed regarding dental services in Norfolk.
One third (commonest reason) did not feel that they needed any dental
treatment.
The Parent group indicated they would they would be encouraged to attend if
it was free of charge and pain free.
25% said they would be encouraged to go if they had a specific need or
problem.
10% said that ease of finding a dentist or having a dentist available would
encourage them to attend.
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Oral Dental Health Needs Assessment for NHS Norfolk
•
•
10% said more available NHS dentists would result in more frequent
attendance.
The Polish group felt they would be more likely to use UK services if, information
was clearer, costs lower and more choice was available. They also expressed a lack
of confidence in the level of cleanliness and quality of care.
Choosing a dentist: 3 strongest drivers were:
• Habit – returning to a long-standing dentist
• Proximity to home: However 25 of respondents said they would be prepared
to travel up to 5 miles. 33% prepared to travel up to 10 miles and 33%
prepared to travel more than 10 miles to attend a dental appointment.
• Recommendations from friends
NHS versus private:
• 69% had NHS treatment, 28% private and only 1% a mixture of the two.
• Older respondents and those of higher social grade were more likely to have
had private treatment.
• The majority who reported they went private said that they did so because of
a lack of availability of NHS dentists or that there was no choice but to have
private treatment. A further 20% said that their dental practice had changed to
a private practice. 10% said that they chose private treatment for a better
quality of care.
Satisfaction with children’s dental services in Norfolk:
Generally this was high – nearly 80% almost four fifths of respondents with children
were satisfied. Of those not satisfied:
25% said that this was due to the lack of NHS practices in the area.
20% were dissatisfied with the location and transport links to the
dental practices
The Dentist’s communication with children was poor.
Lack of automatic registration of children at the parents’ practice.
Overall ratings for different aspects of dental services were good.
o Over 83% respondents reported a very good level of cleanliness in their dental
practice.
o 75% reported a very good level of both privacy/dignity and compassion and
respect.
o 74% rated the standard and quality of care was highly rated or very good and a
further 19% saying it was fairly good.
o 43% of respondents rated the length of wait for an urgent appointment as very
good, with a further 16% reporting it fairly good. However, this is not to say that the
remaining rated their dental practice poorly in this respect as a response to this
question was that they had not experienced any waits.
o As is often found when rating health services, older respondents tended to be
more positive about the service they had received.
o Those who had private dental care on their last visit to the dentist were also more
positive about the service that they had received than those who had received
NHS dental care.
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Oral Dental Health Needs Assessment for NHS Norfolk
Areas of concerns:
o Respondents were less positive about the accessibility of services, with 17%
rating the transport facilities and access to their dental practice as fairly or very
poor. Car parking facilities were also rated less positively with over one third
(35%) of respondents finding these poor at their dental practice.
Suggested priorities for Improvements:
o The top priority for most respondents was increased access to general dentistry
and also to NHS dentists in particular, which reflects the difficulty some felt they
had in finding an NHS dentist.
o School dentistry and orthodontics were a high priority
o The lower rated services amongst the customer groups were
Domiciliary services for the housebound
Sedation services for particularly nervous patients
Car parking
o For the Polish group, clear information on how and where they could register for dental
services (in Polish if possible). Especially clear information on services and costs.
Conclusion
The encouraging picture from this survey is that eight in ten of Norfolk’s residents
had visited a dentist in the last year and only 1% said they had never visited the
dentist. Furthermore, over two-thirds have been to the dentist within the last six
months, indicating that the large majority of residents were well aware of the need to
safeguard their dental health and are were prepared to regularly to visit their dentist.
8.4 Compliments, Complaints and PALs.
PALS contacts.
The number and types of concerns received from the public by NHS Norfolk, Norfolk
and Norwich University Hospital (NNUH) and the Queen Elizabeth Hospital in the
previous 12 months were as follows:
NNUH
o 37 calls received accounting for 1.1% of their total PALs enquiries.
o All of the calls bar one were referred to NHSN PALS
The Queen Elizabeth Hospital, Kings Lynn
No dental enquires received
NHS Norfolk
The majority of enquires to PALS were patients asking how to access an NHS
Dentist. Patients can also access this information via an interactive map on NHS
Norfolk Intranet.
Other complaints and enquires included:
-
Treatment work requiring assessment by NNUH
Home visits
Charges
How to access emergency treatment
Quality of treatment
Attitude of staff
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Oral Dental Health Needs Assessment for NHS Norfolk
Summary points – Section 8 Public Voice
Regional surveys
There have been no significant changes in satisfaction with dentistry in NHS
Norfolk.
NHS Norfolk remains at the top for levels of usage of dentists.
While both remain stable, satisfaction with wait for appointments and flexibility of
appointments is below the SHA average.
NHS Norfolk has fallen more than 5 places in the rankings, to the bottom 2, on
both these measures.
Further to this, NHS Norfolk is in the bottom 5 of the rankings for acceptability of
distance to travel and likelihood of using NHS dentists, though still in line with the
SHA average.
Local surveys
The encouraging picture from this survey is that eight in ten of Norfolk’s residents
had visited a dentist in the last year and only 1% said they had never visited the
dentist. Furthermore, over two-thirds have been to the dentist within the last six
months, indicating that the large majority of residents were well aware of the need
to safeguard their dental health and are were prepared to regularly visit a dentist.
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Oral Dental Health Needs Assessment for NHS Norfolk
Section 9: List of Figures and Tables
Figures
Figure 1:
Figure 2:
Figure 3:
Figure 4:
Figure 5:
Figure 6:
Figure 7a:
Figure 7b:
Figure 8:
Figure 9:
Figure 10:
Figure 11:
Figure 12:
Figure 13:
Figure 14:
Figure 15:
Figure 16:
Figure 17:
Figure 18:
Figure 19:
Figure 20:
Figure 21:
Figure 22:
Figure 23:
Figure 24:
Figure 24:
Figure 25:
Figure 26:
Figure 27:
Figure 28:
Figure 29:
Figure 30:
Recent population increases in Norfolk (Mid 2002-2008, ONS)
Population projections for Norfolk: 2010 and 2020 (source: ONS)
males and females 0 – 19 by District in Norfolk (ONS data, 2008)
Proportion of Population 65+
Proportion of Population 80+
Map showing Proportion of Population 65+ in Norfolk
Estimated Ethnic composition of England, 2007 mid year estimate
(ONS Experimental Statistics)
Estimated Ethnic composition of NHS Norfolk (residents), 2007 mid
year estimate (ONS Experimental Statistics)
Deprivation in Norfolk
Number of LSOAs for Norfolk and NHS Norfolk in each national
deprivation quintile
Number of LSOAs in each national quintile by district
Reduction in dental decay amongst children in UK, 1979 – 2009.
Mean Number of Teeth with Obvious Decay Experience by SocioEconomic Status of Household in the UK 2003*
The Proportion of 5 Year Olds (2003/4) and 11 Year Olds (2004/5) with
No Decay Experience in Norfolk and Waveney PCTs
The Proportion of Adults with No Natural Teeth in England, 1968–1998
The heavy metal wave (Steele, 2009)
Proportion of Adults with Decayed/Unsound Teeth or Periodontal
(Gum) Disease by Social Class
Teeth Condition Among Dentate Adults in England by Jarman Area
Reported Usual Reason for Dental Attendance of Dentate Adults by
Social Class
Dental Status of Adults in England by Region
The Underlying Causes of Oral Health
The risks, common between oral and other chronic diseases
Year R and Year 6 % overweight and obese 2007 – 2008 in Norfolk
(source: National childhood Measurement Programme)
map of residential and care homes: Source NHSN 2010
Oral Health Promotion Activities Aimed at Reducing Oral Health
Inequalities in Young Children
Priorities for investment in oral health (Steele 2009)
Access trend analysis for Norfolk – source BSA Vital Signs
Orthodontic contracts in NHS Norfolk
Map showing sedation service provision in Norfolk
Orthodontic referrals by age 2009/10
Citizen’s Advice Bureau Data on How People Go About Finding an
NHS Dentist
The Course of Action Taken by Respondents if Citizens Advice Bureau
Survey Who Were Unable to Find an NHS Dentist
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Oral Dental Health Needs Assessment for NHS Norfolk
Tables
Table 1:
Table 2:
Table 3:
Table 4:
Table 5:
Table 6:
Table 7:
Table 8:
Table 9:
Table 10:
Table 11:
Table 12:
Table 13:
Table 14:
Table 15:
Table 16:
Table 17:
Table 18:
Table 19:
Table 20:
Table 21:
Numbers of tourists to Norfolk and nights stayed. (Source: Tourist
office)
Domains of multiple deprivation and their weight
Worst and least deprivation by district (measured by IMD 2007)
IMD score and rank of Norfolk districts within 354 in England (1 = most
deprived).
Index for child wellbeing (2009) Source: Public Health, NHSN
Dental survey results National comparison: five year olds 2007 – 2008.
Local data on 5 year olds in Norfolk 2007 – 8
The Decay Experience of 12-year-old Children in Norfolk (The English
NHS Dental Epidemiology Programme Survey of 12 year olds, 2008/9)
Population projection for number of 12 year olds in Norfolk, with chart.
Source: ONS/Norfolk County Council.
Places commissioned by Norfolk Social Services for people aged 65+in
residential and Nursing Care on 30/06/2010.
Prisons in Norfolk and occupancy, 2010 (Source: Prison commissioner,
NHS Norfolk)
Natural Water Fluoride Levels in Norfolk Parishes 2003
Priorities for investment in oral health and their impact on secondary
care service costs
Demonstrating the changes in dental patient numbers from June 2009
– June 2010
Orthodontic UOA’s by location within Norfolk
Rates of Access and Reviews – source BSA Vital Signs
Comparative Secondary Care Referrals
Secondary care QEH activity data – selected procedures 2009/10.
Secondary care NNUH Activity data 2009/10
NHSN Performance Management Dentistry Initiatives
NHSN Performance Management Dentistry Initiatives with risks and
mitigation
86
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Oral Dental Health Needs Assessment for NHS Norfolk
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nd