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A Needs Assessment for
Primary Care Dental
Services in Warwickshire
Improving Access to NHS Dentistry
2009/2010
NHS Warwickshire
Table of Contents
1. Background ........................................................................................................................3
2. The Oral Health Needs of Warwickshire ........................................................................5
2.1 The profile of Warwickshire population .......................................................................5
2.2 Oral Health in Warwickshire...........................................................................................6
3.
Dental Services in Warwickshire ..............................................................................25
3.1 Primary Care Dental Services......................................................................................25
4.
4.1
5.
Gap Analysis ................................................................................................................31
Recommendations.................................................................................................32
Conclusion ...................................................................................................................35
Appendix 2............................................................................................................................37
2
1. Background
Access to NHS dentistry has been identified as a chronic problem that requires urgent
attention. The recent Ipsos-MORI survey (2008)1 identified access to NHS dentists as
the top priority for improvement amongst NHS services in Warwickshire. The lack of
access to dental care is one of the contributory factors to oral health inequalities
leading to poor oral health which can have significant physical, psychological, social
and economic impacts on the population and society.
In the 2008/09 Operating Framework2 Primary Care Trusts (PCTs) were set the
objective of ensuring year on year improvement in the number of patients accessing
NHS dental services, as measured by the vital sign indicator - VSB18. In the 2009/10
Operating Framework3 PCTs have been urged to continue to develop dental services
to meet local needs for access, quality of care and oral health, in order to provide
access to anyone who seeks help in accessing services. Furthermore the VSB18
indicator is now a Tier 1 performance management tool similar to MRSA targets,
which signifies the high importance that the Department of Health attaches to
improving access to NHS dentistry.
Currently about 58% of the Warwickshire population have had access to a NHS
dentist within the last two years as at 31 March 2009. This is about 304,389 patients and
represents a 2% drop on the baseline figure of 60% which is the proportion that used a
NHS dentist in March 2006.
The population of Warwickshire is expected to grow to 545100 by 2011 and the PCT
has been set a target of 63% of the population having access to a NHS dentist by
2011 [this is the number of people who would use NHS dental services within a period
of 24 months if supply met expressed demand at March 2011]. In terms of numbers
this represents about 39000 additional new patients in what is less than a three year
period currently. In order to meet this target we need to develop and commission
services that are based on local needs and are geared towards improving oral
health and reducing the inequalities in dental health.
The aim of this needs assessment is to serve as the basis for the effective
commissioning of primary care dental services in Warwickshire with a focus on
achieving improved oral health and access gain to quality NHS dental services.
The objectives include:
1. Identify the oral health needs of the local population
2. Describe existing service provision
3. Identify any gaps and recommend the level of resources needed to meet
them.
Other national and regional policy documents and initiatives informing the Dental
Access Programme include:
•
“High Quality Care for all” NHS Next Stage Review sets out the strategic vision
that will see the NHS deliver high quality care for all users of services in all
aspects4.
•
“Our Vision for Primary and Community Care” sets out the next stage in the
journey of primary and community care. The ambitions for community based
NHS services are based on four broad themes: people shaping services,
promoting healthy lives, continuously improving quality and leading local
change5
•
Choosing Better Oral Health – An Oral Health Plan for England6 published in
2005 and designed to support PCTs in meeting their responsibilities of
commissioning oral healthcare that is evidenced-based and responsive to
local needs.
•
Delivering Better Oral Health: an evidenced-based preventive toolkit7. This
preventive guide is designed to support PCTs and dental teams in the delivery
of a more preventive and evidenced-based approach to dental care.
•
The NHS Dental Review ( The Steele Review) commissioned in December 2008
published its report8 in June 2009 with the overarching aim of ensuring that the
NHS Dental service moves from a service focused on activity to one that is a
true oral health service. The review made 38 recommendations based on
clearer care pathways for patients, clearer information for the public on how
to access NHS dentistry and clear guidelines for dentists on care pathways,
quality and what the NHS offers. The government has accepted the
recommendations and set up an implementation board that intends to run a
series of pilots to test all aspects of the new service model.
•
Investing for Health (IfH) the West Midland Strategic Health Authority’s
framework for improving health and health services in the West Midlands. The
oral section of the strategy has the overall goals of –
1
o
Ensuring that patients throughput the West Midlands are able to
access high quality NHS dentistry locally and conveniently;
o
Achieving a greater focus on health improvement and disease
prevention in dentistry, so as to reduce inequalities in dental health
and build further on our position of having the best children’s teeth in
Europe, and extending that benefit through the adult population.
IPSOS-MORI Report 2008 Attitudes to healthcare in the West Midlands
Department of Health. The NHS in England: the Operating Framework for 2008/9. Gateway 9120, December
2007
3
Department of Health. The Operating Framework 2009/10: for the NHS in England. Gateway 10967, December
2008
4 Department of Health. High Quality Care for All NHS Next Stage Review Final Report. Gateway 10106, June 2008
5
Department of Health. NHS Next Stage Review: Our vision for primary and community care. Gateway 10096,
July 2008.
6 Department of Health. Choosing Better Oral Health: An Oral Health Plan for England. London: Department of
Health; 2005.
7
Department of Health. Delivering better oral health: An evidence-based toolkit for prevention. Gateway 8504,
September 2007
8
Department of Health. The review of NHS dental services in England. Gateway 12070, June 2009
2
4
2. The Oral Health Needs of Warwickshire
2.1 The profile of Warwickshire population
Warwickshire PCT or NHS Warwickshire as it is now commonly known was formed in
2006 with the merger of South Warwickshire, North Warwickshire and Rugby PCTs. It
has coterminous borders with Warwickshire County and covers an area that stretches
77 miles from No Mans Heath in the north to Little Compton in the south and 44miles
from Sambourne in the west to Flecknoe in the east.
The mid-2008 resident population for Warwickshire has been estimated at 530,700 by
the Office of National Statistics (ONS). The working age group (16 – 64M/59F) makes
up 61% of the population, older people (65M/60F) make up 21% and children (0 – 15)
make up the remaining 18%.
The population of Warwickshire is projected to reach a total of 637,400 by 2031 – an
increase of about 22% over the 2006 ONS estimate. The districts of Warwick, Stratfordon-Avon and Rugby are expected to have the highest growth in population whilst
North Warwickshire and Nuneaton & Bedworth are expected to have considerably
less growth (Table 1).
Across Warwickshire, the highest rates of projected population growth are among the
age groups 65 and over. The rate of growth increases with age with those aged 85
and over projected to increase by over 160% by 2031.
In summary the demographic picture of the Warwickshire population is a rapidly
growing and ageing population with implications for planning of services and
resource allocation. The rapidly growing age groups of 65 and over are likely to have
a cohort who experienced high levels of dental disease which have been treated
with fillings and other restorations (“the heavy metal generation”)1 and who will have
high maintenance needs as they age.
Table 1Warwickshire Districts Population Growth 2006-2011
Area
Total Population (Thousands) % Change
2006
2011
2006-2011
North Warwickshire
62.3
63.5
1.9%
Nuneaton & Bedworth
120.7
123.5
2.3%
Rugby
90.2
93.8
4.0%
Stratford-on-Avon
116.1
122.1
5.2%
Warwick
132.9
142.1
6.9%
Warwickshire
522.2
545.1
4.4%
Source: Office of National Statistics
5
2.2 Oral Health in Warwickshire
Oral health is integral to general health and essential for wellbeing. Good oral health
implies being free of largely preventable diseases and disorders that affect the teeth,
gums and supporting bone and the soft tissues of the mouth, tongue and lips. The
most common oral diseases are dental caries (tooth decay) and periodontal disease
(gum disease). Other conditions include oral cancer, developmental disorders such
as cleft lip and palate and malocclusions.
The causes of oral diseases are multifactorial and many of the key factors that lead to
poor oral health are risk factors for other diseases. The common risk factors include
diets high in sugary foods and fizzy drinks, smoking, excessive alcohol consumption,
poor oral hygiene, inappropriate infant feeding practices and inadequate exposure
to fluoride. People living in areas of material and social deprivation and other
vulnerable groups in society have poorer oral health and they often access dental
services less frequently. Poor oral health also has a major financial and psychosocial
impact on both the individual and society at large.
There have been great improvements in the dental health of children nationally over
the past 30 years but teeth decay remains a significant public health problem in
many parts of the United Kingdom, especially in socially deprived, non-fluoridated
communities. In Warwickshire where the fluoride levels in the drinking water have
been adjusted to 1 part fluoride to one million parts water for over 80% of residents,
there has been significant improvements in the dental health of Warwickshire
children.
Dental health of 5-year-old children
Epidemiological surveys of the dental health of 5-year-old children have been
conducted biennially since 1987 under the auspices of the British Association for the
Study of Community Dentistry (BASCD). The results of the recent BASCD survey of 5
year old children conducted in 2007/8 school year shows that children in
Warwickshire have better dental health when compared to the West Midlands and
England averages. The prevalence of tooth decay in 5 year old children in 2007/8
was 20.60% which was significantly better than the figures reported for the West
Midlands and England (Figure 1). This means that almost 80% of 5-year-old children in
Warwickshire are free from obvious tooth decay. Across the whole of the population
of 5 year old children examined in Warwickshire, the average dmft2 per child was 0.58
which was significantly better than both the West Midlands and England averages
(Figure 2). When we consider the decay experience amongst those children who are
not free of obvious disease (dmft >0), the average dmft was 2.75 per child (Figure 3).
6
Figure 1
5 year old caries prevalence 2007/08
35.00
30.00
dmft > 0 (%)
25.00
20.00
Warwickshire
15.00
10.00
28.90
30.9
West Midlands
England
20.60
5.00
0.00
Warwickshire
West Midlands
England
Source: The Dental Observatory
Figure 2
5 year old caries experience [dmft] 2007/08
1.20
1.00
0.80
dmft
Warwickshire
West Midlands
0.60
1.11
0.97
0.40
0.58
0.20
0.00
Source: The Dental Observatory
7
England
Figure 3
Average caries experience for 5 year
olds with decay [dmft >0]
4
Average dmft for dmft >0
3.5
3
2.5
Warwickshire
2
1.5
3.23
3.45
West Midlands
England
2.75
1
0.5
0
Warwickshire
West Midlands
England
Source: The Dental Observatory
Patterns within Warwickshire
Within Warwickshire there is some variation in the dental health of 5 year old children
at district level. Figure 4 shows the decay experience of 5 year olds in the five local
district areas. The two districts in the north, Nuneaton & Bedworth and North
Warwickshire have the worst caries levels in the county. The chart shows that children
in Nuneaton & Bedworth have significantly poorer dental health when compared
with the districts of Rugby, Stratford and Warwick. The pattern is very much the same
when we compare the disease prevalence (dmft >0), prevalence of active disease
(dt >0), and the care index at district level. The most deprived districts of Nuneaton &
Bedworth and North Warwickshire have the poorer outcomes (Figure 5).
8
Figure 4
5 yr old Caries Experience [Mean dmft]
Warwickshire Districts 2007/08
1.00
0.80
North Warwickshire
dmft
0.60
Nuneaton &
Bedworth
Rugby
0.81
0.40
0.68
0.42
0.20
0.53
0.48
Stratford-on-Avon
Warwick
0.00
Source: The Dental Observatory
Figure 5
35.0
5yr old Caries Experience Warwickshire Districts 2007/08
30.0
25.0
North Warwickshire
20.0
Stratford-on-Avon
9
20
22
dt > 0
24
dmft >0
5.0
21
19.4
24.8
13.5
15.9
15.4
10.0
Rugby
22.7
26.5
17.0
18.1
18.6
15.0
Nuneaton & Bedworth
0.0
Source: The Dental Observatory
9
Care Index
Warwick
The Care Index
The care index is the proportion of teeth with caries experience which have been
filled3. It indicates the level of restorative care received by 5-year-old children but
gives no indication on the quality of care received. In the 2007/08 survey the care
index for Warwickshire was 18% compared to a regional average of 13% and a
national average of 14%.
Figure 5 above shows the considerable variation at district level in terms of the care
index. All the districts apart from Nuneaton & Bedworth have better than county
average performance with a range of 20 – 24%. Nuneaton and Bedworth is
significantly worse with only 9% of the teeth with caries experience having received
restorative care.
Note
The 2007/8 survey required positive consent to be obtained from the parent or
guardian of every child taking part in the survey. (Previously, parents were informed of
the survey and unless they objected children were examined). The overall response
rate was lower than previous surveys and it is possible that this factor has introduced
an element of non response bias. As a result the Deputy Chief Dental Officer for
England has advised that direct comparisons with previous surveys should not be
made4. In compliance with this directive further comparisons of 5-year-old dental
health does not make use of the 2007/8 results.
Trends in Dental Health of 5-year-old children
The dental health of 5-year-old children in Warwickshire has shown significant relative
improvements since the surveys began in 1987 but in the last decade dental health
has remained relatively stable in Warwickshire and still better than the West Midlands
average (Figures 6 & 7). There has been a slight increase in the severity of the disease
but the prevalence level has remained flat. This summation does not include the
results of the 2007/8 survey which shows a significant reduction in the severity of the
disease and a drop in the prevalence level.
10
Figure 6
5yr old caries experience [dmft]
1.20
1.00
Average dmft
0.80
0.60
Warwickshire
1.02
0.94
0.40
0.70
0.65
1999/00
2001/02
1.02
1.02
0.75
0.79
2003/04
2005/06
West Midlands
0.20
0.00
Source: BASCD Survey Reports
Figure 7
5yr old Caries Prevalence
30.00
26.84
Warwickshire
26.34
31.56
26.31
10.00
24.59
15.00
30.14
20.00
31.52
25.00
26.01
Caries Prevalence [dmft >0]
35.00
5.00
0.00
1999/00
Source: BASCD Survey Reports
11
2001/02
2003/04
2005/06
West Midlands
Dental health of 12-year-old children
Epidemiological surveys of the dental health of 12-year-old children have also been
conducted every four years since 1988 under the auspices of BASCD and recently by
the North West Observatory. These surveys look at the permanent teeth of 12-year-old
children and the last survey with published results was conducted in 2008. As with the
5-year-old children these surveys have shown significant improvements in the dental
health of 12-year-old children in Warwickshire in terms of tooth decay experience
and in the proportion of children suffering tooth decay (Figures 10 & 11). The average
DMFT has fallen from about 1tooth per child in 1988 to 0.63 tooth per child in 2008. The
proportion of children with tooth decay experience has also fallen from a high of
43.2% in 1988 to about 28% of the 12-year-old population in 2008.
The most recent survey of 12-year-old children indicates a significant increase in the
severity of the disease and an increase in the prevalence as well. This is a worrying
trend and efforts would be required to ensure that the gains achieved in terms of
good oral health of 12 year children is protected and improved upon.
Figure 8
12 Year Old Caries Experience - DMFT
1.4
1.2
0.8
0.63
0.63
0.68
2000
2008
0.43
0.2
0.51
0.56
0.4
0.75
West Midlands
0.85
0.6
Warwickshire
1.04
1.27
Average DMFT
1
0
1988
1992
1996
Source: BASCD & The Dental Observatory Survey Reports
12
Figure 9
12 Year Old Caries Prevalence
60.0
DMFT >0 (%)
50.0
40.0
Warwickshire
West Midlands
30.0
20.0
49.4
43.2
38.5
30.8
10.0
34.4
26.4
31.3
22.6
1996
2000
27.9
32
0.0
1988
1992
2008
Source: BASCD & The Dental Observatory Survey Reports
Adult Dental Health
There is hardly any local data on adult oral health and information on the state of
adult oral health is provided by national surveys conducted every 10 years. The 1998
survey showed considerable improvements in adult oral health with 13% of adults
having no teeth compared to 21% in 1988. Tooth loss was more common in the
elderly as over two-thirds (69%) of all adults with no teeth were aged 65 and over and
39% were aged 75 and over. Figure 12 shows the trend in tooth loss in the Midlands.
Differences between regions and social groups were also evident. England was
divided in to 3 regions – the South, Midlands and the North. When the proportions of
adults retaining some natural teeth were compared, the Midlands and the North
were closely matched, with 87% of men and 83% of women in the Midlands retaining
some natural teeth. The South of England fared better than the North and the
Midlands with 93% of men and 88% of women having at least some natural teeth.
The Midlands had healthier teeth with 42% of dentate adults having sound teeth
compared with 41% for the North and South. Decayed and unsound teeth were more
common in the North and this was particularly true among 16 to 24 year olds; 70% in
the North had at least one decayed or unsound tooth compared with 46% in the
Midlands and 38% in the South.
Variations in dental health between social groups were also evident. People from
non-manual backgrounds were significantly more likely to have retained their teeth
than those from manual backgrounds. In the Midlands 92% of men and 89% of
women in social class I, II, IIINM had some natural teeth compared to 79% of men and
74% of women in social class IV, V.
People’s attitudes towards their dental health and related behaviour have also
changed with successive surveys. The proportion of dentate adults who reported
attending for a regular check up had increased from 43% in 1978 to 59% by 1998.
13
There have also been changes in treatment preferences and patient expectations.
There has been a marked increase in the proportion of respondents saying they
would prefer an aching back tooth to be filled rather than taken out, from 52% in
1968 to 80% in 1998 in England and Wales. The proportion of dental adults who would
be very upset if partial denture replacement of lost teeth were needed had risen
from 22% in 1988 to 27% in 1998 and the proportion who thought they were likely to
need full dentures sometime in the future had fallen from 13% in 1988 to 10% in 1998.
There has been some improvement in adult dental health but there are still social and
geographical inequalities. People are living longer and keeping their teeth longer
and disease patterns have started to change and these factors coupled with rising
expectations have given rise to the future prospect of more complex and expensive
dental treatment. This has important implications for future workforce development
and service provision.
Figure 10
Proportion of Adults with no Natural Teeth in the
Midlands by Age
Percentage
100
80
60
83
40
20
0 0 0
4 1 1
10 6 1
16-24
25-34
35-44
33
23 11
47 40
69
45
26
0
1978
1988
45-54
55-64 65and over
1998
Source: Adult Dental Survey 1998
Periodontal (Gum) Disease
Periodontal disease is a chronic bacterial infection that affects the gum and bone
supporting the teeth. It ranges from simple gum inflammation to serious disease that
results in major damage to the soft tissue and bone that support the teeth. In the
worst cases, loss of gum attachment to teeth leads to pocketing and teeth may
become loose and subsequently lost. The risk factors include poor oral hygiene,
smoking, diabetes, stress, genetic susceptibility, pregnancy and certain medications.
It has been suggested that smoking may be responsible for more than half of the
cases of gum disease in adults5. There is also emerging research associating
14
periodontal disease to other medical conditions and in particular to coronary heart
disease6. It is thought that periodontal disease may be a risk factor for coronary heart
disease but more research is however required to prove this assumption.
The Adult Dental Survey (1998) showed that 54% of dentate adults in the UK had some
pocketing around their teeth but only 5% had deep pocketing (6mm or more) (Figure
13). The prevalence of pocketing and loss of attachment increased with age. For
example, the proportion of dentate adults with some loss of attachment increased
from 14% among those aged 16 to 24 years to 85% of those aged 65 and over.
Periodontal disease is preventable and the focus is usually on maintenance of good
oral hygiene by the individual and attempts to reduce the smoking prevalence in the
community (smoking cessation programmes). The Department of Health in England
has made available to all dental practices an evidence based toolkit for prevention
of oral diseases ‘Delivering Better Oral Health’. The PCT should explore means of
providing support for dentists to adopt this guidance as part of their normal practice.
The toolkit advises dental teams to note the smoking status of their patients and to
provide advice on quitting to smokers and tobacco users. In addition to this NHS
Warwickshire is running a pilot using dental teams to provide a full stop smoking
service for patients who want to stop. The dental teams involved have received
training that will enable them to provide intensive one-to-one support for smokers
who want to stop in their dental practices. The outcomes will be monitored and
dental practices will be compensated based on the degree of success achieved.
Depending on the result of the evaluation of the pilots the scheme may be rolled out
to all dental practices across Warwickshire.
Figure 11
% affected
Prevalence of periodontal disease as indicated by
pocketing in UK dentate adults, 1998
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
16-24
25-34
35-44
45-54
55-64
65 and
over
Age Group
No pocketing above 3.5mm
Pocketing 4mm - 5.5mm
Pocketing 6mm - 8.5mm
Pocketing above 8.5mm
Source: Adapted from Morris, A J. et al (2001)7
1
NHS dental services in England: An independent review by Professor Jimmy Steele; June 2009.
15
All
2
dmft index – decayed, missing and filled teeth – refers to primary or baby teeth and is a measure of the severity
of decay experience
3 Care Index - derived by taking the number of filled teeth and dividing by the total number of dentinally
decayed, missing and filled teeth and converting to a percentage (ft/dmft)
4
CDO UPDATE December 2009, Department of Health, Gateway Reference no 13131.
5
Tomar S.L. and Asma S. (2000) Smoking attributable periodontitis in the United States: findings from NHANES III.
J. Periodontology; 71:743-51
6
Bahekar AA, Singh S, Saha S, Molnar J, Arora R. Am Heart J 2007 Nov;154(5):830-7.
7
Morris A.J., Steele J. and White D.A. The oral cleanliness and periodontal health of UK adults in 1998. Br. Dent.
J.; 191: 186-192
16
Vulnerable People/Groups
There is evidence that people/groups in residential care (such as older people,
people with a learning disability or mental health problem, people who are physically
or medically compromised and people in secure units) are more likely to have poor
oral health and inadequate or restricted access to dental services1. Disabled children
and adults have the same entitlement to good oral health as the rest of the
population2. This inclusive description covers large numbers of client groups and
within each group there will be a ‘pyramid spectrum’ of need and dependency, with
limited numbers of people at the highest level of need and dependency. Oral health
is an important factor in overall health and well-being. Good oral health empowers
disabled children and adults, giving them the confidence to enable them to reach
their full potential in participating in all aspects of society.
Information concerning the epidemiology of oral disease in these at-risk groups is not
readily available. National dental epidemiological studies have not routinely
gathered information from disabled children and adults. There is, therefore, a
necessity for PCTs to carry out oral health needs assessments for these groups to
facilitate the development of inclusive strategies that best serve the whole
population. NHS Warwickshire intends to undertake an oral health survey of care and
nursing home residents as part of the 2010/2011 dental epidemiological programme.
Disability
It is generally estimated that 3% of children have a disability3. Incidence of disability
may be higher in areas of deprivation and some causes of disability are more
prevalent in some minority ethnic groups. The chart below shows the number of
disability living allowance claimants aged below 65 in Warwickshire as at November
2008. The district of Nuneaton and Bedworth has the highest number of claimants in
the county more than the districts of North Warwickshire and Rugby put together. This
may imply that Nuneaton and Bedworth has higher numbers of disabled people than
the other districts in Warwickshire.
DLA Cases in Payment November 2008
4,000
3,800
3,500
3,000
North Warwickshire
2,500
2,280
2,010
2,000
1,820
Stratford-on-Avon
1,600
Warwick
1,500
1,000
500
0
North Warwickshire
Source: www.pansi.org.uk
17
Nuneaton and
Bedworth
Rugby
Nuneaton and
Bedworth
Rugby
Stratford-on-Avon
Warwick
Learning Disability
Learning disability is defined as a significant impairment of intelligence and social
functioning acquired before adulthood4. It is estimated that between 1.3% and 3.5%
of the adult population in the UK have a learning disability. About a quarter of the
total population with learning disabilities are profoundly disabled with additional
disabilities5. There has been little change in the number of people aged over 20 years
known to have learning disabilities with a small increase in the number living at home,
with a migration from hospital to community accommodation. In Warwickshire the
number of adults with moderate to severe learning disabilities is predicted to increase
by 9% from 1801 to 1971 by the year 2030. There is some variation in the prevalence
rates at the district level and the chart shows the predicted numbers of the adult
population with moderate to severe learning disability in Warwickshire. The highest
number of cases occurs in the Warwick district and most of the predicted increases
also occur in this district.
Predicted Cases of Moderate or Severe Learning Disability
700
600
500
400
300
200
100 www.pansi.org.uk
Source:
18
Oral Cancer
Oral and pharyngeal cancers include cancers of the lip, tongue, mouth, salivary
glands, oropharynx, piriform sinus, hypopharynx and other and ill-defined sites. The
majority of oral malignancies are squamous cell carcinomas and about a third of oral
cancers occur in the mouth cavity and a similar proportion is diagnosed on the
tongue. The risk of developing oral cancer increases with age and in the UK the
majority of cases occur in people aged 50 or over. It is more common in men than
women but the sex ratio has fallen from around 5:1fifty years ago to less than 2:1
today.
In 2006 5325 people in the UK were diagnosed with oral cancer which accounted for
2% of all cancer cases diagnosed in the UK for that year. Oral cancer incidence has
been rising steadily in males and females in recent years. The age standardised
incidence of oral cancer in British males which was around 7 per 100000 males
between 1975 and 1989 has risen to 11 per 100000 in 2006, an increase of 51% since
1989. During the same period incidence trends in females have been similar with an
average increase of 2.7% each year since 1989. Further analysis of these trends shows
that most of the increases have occurred in men in their 40s and 50s with rates more
than doubling from 3.6 per 100000 for men aged 40-49 and from 11.5 to 27.2 for men
aged 50-59.
The main causes of oral cancer are tobacco usage and excess consumption of
alcohol and these factors together are thought to account for about three-quarters
of oral cancer cases in Europe6. Other risk factors include diet and nutrition, ultraviolet
light, human papilloma virus, immunosuppresion and other factors. Oral cancer
incidence is also strongly related to socioeconomic deprivation with the highest rates
occurring in the most disadvantaged sections of the population.
There were 1851 deaths from oral cancer in the UK in 2007. More men are killed by
oral cancer probably reflecting their higher incidence rates. The overall age
standardised mortality rate has remained fairly stable between 1971 and 2007 for
males and females at around 3.5 and 1.4 per 100000 respectively. These figures mask
the variation in the age-specific trends for mortality. Figures show that whilst the
mortality rates in men aged 75 - 85+ have fallen since 1971, for men aged 45-64 there
has been an increase of 90%.
Survival is very dependent on early diagnosis and patients seen at an early stage can
usually be cured but for those with metastatic disease the aim is to contain the
disease and maximise quality of life. Survival is also dependent on the site of the
cancer as demonstrated by an ONS publication7. Patients with cancer of the lip had
the best outcome with over 90% surviving five years, followed by oral cavity, tongue,
oropharynx and the lowest survival was for hypopharyngeal tumours. Survival is also
better for younger than older patients and it has been shown that deprivation affects
survival rates as well. An analysis of the five year survival rates for 1986-90 patients
showed significant differences between the most affluent and most deprived groups
for cancers of the tongue, oropharynx and oral cavity8.
The main forms of treatment are surgery and radiotherapy and in advanced disease
chemotherapy may be used to enhance the effect of radiation (chemoradiation).
Often treatment can have debilitating consequences for patients resulting in loss of
function and facial disfigurement.
19
Evidence has shown that three-quarters of the disease could be prevented by
elimination of tobacco use and the reduction of alcohol consumption. Smoking
cessation is associated with a 50% reduction in risk of oral cancer within 3-5 years and
the risk for ex-smokers approaches that of life-long non-smokers after ten years of
smoking cessation9. We know that the prognosis is better if patients present early and
so screening for premalignant and early stage disease has been advocated for
prevention and improving outcomes. However, there is insufficient evidence to
support population screening but opportunistic screening of high-risk groups
attending primary care services has been considered to be cost-effective in
improving early detection10. Efforts should be made to encourage opportunistic
screening of high-risk groups attending general dental practices and raising the
awareness of the public about the causes and symptoms of oral cancer.
Incidence of Oral Cancer in Warwickshire
There were 45 cases of oral cancer diagnosed in Warwickshire in 2007. The gender
ratio was 2:1, thirty cases occurred in males and fifteen in females. The majority of the
cases in 2007 occurred in those aged over 55 years, although there were a few cases
in males aged 35-44 years. The age standardised rate has risen from 4.22 persons per
100000 in 1981 to 6.73 persons per 100000 in 2007. Although there has been an
upward trend since 1981 the difference is not statistically significant (Figure 14). The
rate in males has more than doubled from 4.41 per 100000 to 9.4 per 100000 during
the same period. In females the rate has dropped slightly from 4.35 per 100000 to 4.18
in 2007. There was no significant difference between males and females in 2007 and
over the 27 year period significant differences between the sexes has only occurred
in seven of those years.
20
Figure 12 Oral Cancer: Age Standardised Incidence rate, 0-85+, DSR (European),
1981-2007 – Warwickshire PCT
Source: West Midlands Cancer Intelligence System
Mortality
Of the 1851 deaths in the UK from oral cancer in 2007, sixteen of those deaths were in
Warwickshire with 11 deaths in males and 5 in females. The number of deaths has
doubled since 1981 and the overall age standardised mortality rate has gone up
slightly from 1.49 persons per 100000 in 1981 to 2.21 persons per 100000 in 2007 but the
rise is not statistically significant. A comparison of 5 year mortality rates in the West
Midlands for the period 2003 -2007 shows no significant difference between PCTs in
the West Midlands (Figure 15). The overall trend in 5 year mortality rates for
Warwickshire is one of a non-significant slightly downward trend (Figure 16). Although
the overall picture is one of a downward trend, males aged 40 -59 seem to be
bucking the trend as mortality rate has doubled from 3.33 per 100000 in 1981 to 6.78
per 100000 in 2007.
21
Figure 13
Source: West Midlands Cancer Intelligence System
Figure 14 Oral Cancer Mortality Age Standardised Rates 5 year Rolling Average (1981 –
2007) - Warwickshire
Source: West Midlands Cancer Intelligence System
22
Survival
Oral cancer survival is dependent on a number of factors including early diagnosis,
site of the lesion, age of the patient and socioeconomic status. The five-year survival
rate for Warwickshire patients shows an upward trend for all age groups and
deprivation categories although there is no significant change over the period (Figure
17). There is also no significant difference between PCTs in the West Midlands when
we look at the relative 5 year survival rate for the 1992 – 1996 period. This analysis
should be interpreted with caution as a significant proportion of surviving patients
have been classified as resident in an unknown PCT (Figure 18).
Figure 15 Oral Cancer 5yr Relative Survival Rate (1981 – 2002) – Warwickshire
Source: West Midlands Cancer Intelligence System
23
Figure 16
Source: West Midlands Cancer Intelligence System
1
Fiske J, Griffiths J, Jamieson R et al. Guidelines for oral health care for long-stay patients and residents.
Gerodontology 1999; 16: 204-209.
2
Department of Health: Valuing People’s Oral Health. A good practice guide for improving the oral health of
disabled children and adults. London: Department of Health, 2007.
3
Department for Education and Skills/Department of Health (2003). Together From The Start – Practical guidance
for professionals working with disabled children (birth to third birthday) and their families.
4
Signposts for Success in Commissioning and Providing Health Services for People with Learning Disabilities.
Department of Health 1998.
5
British Society for Disability and Oral Health (2001). Clinical Guidelines and Integrated Care Pathways for the
Oral Health Care of People with Learning Disabilities.
6 La Vecchia, C., et al., Epidemiology and prevention of oral cancer. Oral Oncol, 1997. 33(5): p. 302-12.
7
Office for National Statistics. One- and five-year survival of patients diagnosed in 1991-95 and 1996-99: less
common cancers, sex and age, England and Wales. 2005.
8
Coleman, M., P. Babb, and P. Damiecki, Cancer Survival Trends in England and Wales, 1971-1995: Deprivation
and NHS Region. 1999: TSO.
9
Samet, J.M., The health benefits of smoking cessation. Med Clin North Am, 1992. 76(2): p. 399-414.
10
Speight PM, Palmer S, Moles DR, Downer MC, Smith DH, Henriksson M, Augustovski F. The cost-effectiveness
of screening for oral cancer in primary care. Health Technol Assess. 2006; 10(14): 1 - 144
24
3. Dental Services in Warwickshire
3.1 Primary Care Dental Services
Primary care dental services in Warwickshire are provided by independent
contractors who work either as single-handed practitioners or in partnerships. There
are also a growing number of dental corporate bodies’ providers.
The special care dental services which is hosted by NHS Warwickshire’s Provider Arm
also provides primary care dental services for groups with special needs and
operates a few dental access centres for urgent and immediate care. The service
also provides general anaesthetic services for children and special care adults. It also
has a dental public health function which includes epidemiological surveys, dental
screening in special needs schools and oral health promotion activities.
The NHS Dental Services reports 107 active contracts for Warwickshire as at
September 2009. This is made up of 88 general dental contracts (General Dental
Services & Personal Dental Services), 6 orthodontic contracts and 13 Trust-Led Dental
Services (TDS) contracts.
Primary care dental contracts guarantee the contract-holder a gross annual income,
paid net of any NHS patient charges collected. In return the contractor must deliver
an agreed number of courses of treatment, weighted by their complexity, and
measured as Units of Dental Activity (UDAs) for routine dental care and Units of
Orthodontic Activity (UOAs) for orthodontic treatment.
For a majority of the dental contracts their geographical location and size are a
legacy of the period before the advent of local commissioning. The current local
commissioning arrangements give PCTs the flexibility to develop new services to meet
local needs and to reduce prevailing oral health inequalities.
Access to Primary Dental Care Services
Access is a complex multi-dimensional concept which is affected by several factors
relating to contact with health services and the degree of fit between healthcare
service and the client. The factors affecting contact include sociological and
psychological factors such as culture, beliefs, attitudes, expectations and definitions
of sickness which can impact on service use. The ‘degree of fit’ might be affected by
the availability, affordability, accessibility, acceptability and accommodation of the
service.
The primary measure of access to primary dental care services is the number of
people using the service. The indicator used to measure this is the number of patients
who have seen a dentist in the previous 24 months. Table 2 compares the number
and proportion of patients in Warwickshire who were seen by a dentist in the previous
24 months at the start of the new dental contract on 31st March 2006 and at 30th
September 2009. There has been a drop in both the number and the proportion of
patients seen. There was a notable change in relation to child patients with a 6.2%
difference in the number of child patients seen by March 2006 compared to
September 2009. This is important given the requirement for the PCT to increase the
proportion of patients seen to 63% of the population by March 2011. A trend analysis
shows that whilst there has been a notable drop in the proportion of patients seen
since March 2006, we are now in a steady growth phase albeit a slow one. Figure 19
shows that our access rate has always been better than the regional and national
25
averages and we are currently ranked 8th in the West Midlands and 63rd out of 152
PCTs nationally. Although the data indicates that a higher proportion of the county
population have access to dental services when compared to the regional and
national averages, there are still significant inequalities within the county. Our
immediate priority therefore is to improve access to dental services by commissioning
new high quality services where gaps have been identified and to increase the
efficiencies derivable from current contracts.
Table 2 Number and proportion of patients Seen in previous 24 months at the
specified dates
31 March 2006
30 September 2009
Total
Percentage
Change
Adult
Child
Total
Adult
Child
Total
Number
227124
84273
311397
226761
79046
305807
-1.8
Patients as
% of
55.8%
75.5%
60.0%
54.1%
71.1%
57.6%
-2.4
Population
Source: NHS Information Centre for health and social care
Figure 17
Source: NHS Information Centre for health and social care
In terms of availability of primary care dental services, the distribution of
commissioned dental activity as at April 2009, expressed in terms of UDAs per district
shows that the districts of Nuneaton & Bedworth [2.06] and Warwick [2.04] have the
highest UDA per head of population whilst Stratford -on- Avon has the lowest ratio of
0.98 (Table 3). Variations also exist at the sub-district levels with rural localities which
have much lower population density per Km square having little or no availability of
service (Figure 20). It is not surprising therefore that there is considerable variation in
the distances people have to travel to access dental services in the county. People in
the rural east and south of the county have to travel distances of up to 18km to see a
dentist whilst residents living in urban areas travel on average distances less than 4km
to receive dental care (Figure 21).
26
Table 3 Availability of Primary Care Dental Services (UDA/Population Head)
Area
Resident Population Contracted UDAs UDA/Population
62305
86515
1.39
North Warwickshire
120697
248318
2.06
Nuneaton & Bedworth
90221
139395
1.55
Rugby
116074
113240
0.98
Stratford-on-Avon
132935
270529
2.04
Warwick
522232
857997
1.64
Warwickshire
Sources: Office of National Statistics (Mid 2007 Ward population Estimates) and NHS Dental Services
Figure 18 Contracted UDAs 2009/10 and Population Density per Ward
27
Figure 19 Average Distance Travelled and Treatment Locations
Given these factors access rates over a 24 month period at ward level for the 2008/09
financial year also showed significant variation. The highest access rate of 79% was
recorded in Coleshill North ward in North Warwickshire – South Locality and the lowest
rate was 29% in Stoneleigh ward in Warwick Rural locality. A Statistical Process
Control (SPC)i analysis of the access rates showed that 47 out of 105 wards in the
county had access rates that were significantly lower than the average for
Warwickshire (see Appendix 1). Most of these wards are located in the districts of
Stratford-on-Avon and Warwick and are mainly rural with small populations and
relatively poor availability of services. Although 17 of the wards with low access rates
were amongst the 25% most deprived wards in Warwickshire, there was no obvious
association with deprivation levels (see Appendix 2). The impact of service
availability on access to dental services is further demonstrated by findings related to
two proxies for service availability. When we look at service availability in terms of the
UDA per head of population ratio in the localities, the wards with low access rates
were mostly located in localities with ratios of less than 2 UDA/head of population.
i
SPC recognises that variation is inherent in all ‘systems’ and may be due to chance or other
special causes. The questions we need to answer are: Is the observed variation more or less
than we would normally expect? Are there exceptionally good performers? What reasons
might there be for excess variation, and so on? SPC methods are particularly useful for
answering such questions in public health.
28
The other variable which points to the role that service availability has to play in low
access is the average distance travelled to access services. Where people had to
travel an average distance of 9km or more there was generally lower access to
dental services.
Public and Patient Views
NHS West Midlands commissioned an Ipsos-MORI poll in 2006 which found that the
main priority for improvement in the West Midlands was the ease of registering with a
dentist1. Seventy percent of respondents thought that the ease of registering with a
dentist needed at least a fair amount of improvement. When the survey was
repeated in 2008 the perception was that accessing NHS dentistry was still a problem.
It was regarded as one of top four priorities in all the 17 PCTs in the West Midlands for
health services that required some improvement and it was the top priority in 5 PCTs
including Warwickshire.
A survey conducted by Ipsos-MORI on behalf of Citizens Advice amongst a
representative sample of adults in England and Wales and published in 2008 found
that a third of the sample had not been to a dentist. The most common reasons given
for not doing so were lack of access to an NHS dentist (31%) and not needing
treatment (30%)2. A breakdown of the proportion citing lack of NHS accessibility is
given in Table 4 below.
It is obvious that the public and patients regard access to NHS dentistry as a top
priority for improvement and in some instances the perception and the realities on
the ground are not far apart. It is important therefore that when new services are
commissioned, that they are publicised appropriately to enhance maximum
utilisation of those services. There is also an obvious need for a better understanding
of local views on dentistry to inform the development of services that are more
appropriate to meet local needs and improve contact with these services.
Table 4
Total citing Lack of NHS Accessibility
There are no NHS dentists in my local
area taking on new patients
I can’t find an NHS dentist to treat me so
have gone without treatment
I can’t find an NHS dentist so have been
to see a private dentist for treatment
I simply can’t find an NHS dentist
29
31%
19%
4%
10%
8%
Commissioned Dental Activity 2008/2009
The level of dental activity commissioned by NHS Warwickshire in the 2008/09
financial year from independent primary care contractors is shown in Table 5 below.
This does not include orthodontic activity or services provided by the Salaried Dental
Services (TDS contracts). Just over 92% of the contracted activity was delivered by
the practitioners in 2008/09.
In terms of value for money the figures presented below show the level of activity
commissioned for a given level of gross investment and the number of patients seen
for the same level of gross investment.
Table 5
NHS Warwickshire Dental Contracts [GDS & PDS] Summary - April 2008 – March 2009
Contracted
Carry
Total
Percentage Contracted
Number of
UDA April
forward
Contracted of
value - April
patients
2008 to
treated
2008 to
UDA from
and carry
contracted
March 2009
2007/2008 forward
UDA and
March 2009
April 2008
UDA for
carry
(£)
to March
2009
2008/2009
forward
UDA
relating to
achieved
2008/2009
activity
872,161.00
11,564.00
883,725.00
92.4 %
22,227,357.35 264,606
Average
UDA value
25.50
Average
UDA/Patient
treated
3.02
1
Number
of
patients
treated
April
2008 to
March
2009
270,974
Attitudes to Healthcare in the West Midlands for NHS West Midlands (2006); Ipsos-MORI
Dentistry. http://www.ipsos-mori.com/researchpublications/researcharchive/poll.aspx?oItemId=170
2 Access to
30
4. Gap Analysis
This section will identify the areas where current service provision does not meet the
needs of the local community either in terms of availability or acceptability. The
previous sections have demonstrated that the oral health of 5 year old children is
relatively good and stable and that there are some significant differences at district
level in Warwickshire in the caries experience of 5 year olds. It has also been
established that there are significant variations in the access to NHS dental service at
ward level and determined that deprivation levels have had no significant impact on
access to NHS dental services in Warwickshire. We have also found that the main
factor affecting access to dental services is the non-availability of NHS dental services
in people’s local communities as measured by the service distribution
[UDA/Population Head], uptake of services and distance travelled to access services.
Table 6 below identifies the localities and the wards within them where access to NHS
primary care dental services is significantly below the county average. It is Important
to highlight that in some of these localities there are also wards with high access
rates. In some of the wards with low access rates the problem is due to poor uptake
of services as there is evidence that adequate levels of primary care NHS dentistry
has been commissioned. In these areas the focus will be on improving the offering
and exploring avenues to encourage utilisation of available services e.g. social
marketing campaigns.
There are other localities e.g. Rugby Rural and some areas of Stratford on Avon,
which due to their rural nature, low population density and size are not ideal locations
for the normal general dental practice set up. The PCT would have to consider other
alternative options for meeting the needs of these communities including making
more effective use of existing dental access centres currently operated by the
special care dentistry service and developing a mobile dental service.
Some of these localities e.g. Stratford on Avon – Stratford and Southam have had
new services commissioned some of which are already on stream and others will be
on stream in the near future.
The factors that ultimately influenced the recommendation of where to locate
services as part of the Dental Access Programme are:
o The oral health status of the population
o Local availability of NHS dental services
o The local uptake of dental services
o The size of the local population and the projected population growth – capacity to
benefit
o The potential to address prevailing inequalities in access to NHS dentistry
o The resources available for commissioning additional capacity.
The localities identified for possible location of new dental services include:
1. North Warwickshire – East Locality, Hartshill
2. Rugby – Rugby Rural Locality, Dunchurch
3. Stratford on Avon – Alcester, Studley and Henley Locality, Bidford and Salford.
4. Stratford on Avon – Alcester, Studley and Henley Locality, Studley.
5. Warwick – North Leamington Locality, Manor.
6. Warwick – South Leamington and Whitnash Locality, Brunswick.
The proposal is for these six new additional dental schemes to complement the
services already commissioned to improve access to NHS Dentistry in Warwickshire.
31
4.1
Recommendations
1. Service Provision/Delivery
Primary Care –
a. Improve access to dental services by working with Primary Care
Directorate to :
i. Commission six new additional schemes as identified above
ii. Increase the efficiencies derivable from current contracts by
improving performance monitoring.
b. Advocate a continuous quality improvement regime for services provided
by dental practices through:
i. Regular benchmarking on service quality using a ‘Balanced
Scorecard’ approach as developed and agreed with the Local
Dental Committee
ii. Ensuring that practices meet the standards required for the Care
Quality Commission registration including the requirements for
decontamination and infection control (HTM01-05)
iii. Reviewing the practice inspection programme to ensure it is fit for
purpose.
2. Oral Health Improvement
a. Advocate the continuation of the fluoridation of the water supply in
Warwickshire to help with reducing the existing dental health inequalities
b. Promote the common risk factor approach to health promotion and
integrate oral health promotion into other health promotion campaigns
such as smoking cessation, healthy eating and healthy weights
programmes.
c. Encourage more dental practices to be health promoting practices
through active participation in the smoking cessation and healthy weights
programmes
d. Promote the inclusion of oral health in the care plans for care home
residents
e. Encourage early attendance of children to dental services to benefit from
preventive measures such as Fluoride varnish applications and oral
hygiene advice
f. Commission an education campaign on the risk factors, signs and
symptoms of oral cancer and the benefits of early detection.
32
Table 6 Warwickshire Localities and Wards with Low Access Rates to NHS
Dentistry 2008/09
%
Average
Numerator
Accessing
Distance
(No. of
Denominator
NHS
Travelled
Cases)
(Population)
Dentistry
[km]
Area
North Warwickshire - South Locality
Arley and Whitacre
3,031
5,421
56%
8
Baddesley and Grendon
2,211
4,045
55%
9
Dordon
1,744
3,088
56%
6
Atherstone North
1,805
3,529
51%
6
Atherstone South and Mancetter
1,951
3,741
52%
6
Atherstone Central
1,942
3,732
52%
5
Hartshill
2,105
3,691
57%
4
Curdworth
1,854
3,353
55%
6
Hurley and Wood End
2,116
3,878
55%
8
4,014
7,417
54%
2
Kingswood
3,873
6,837
57%
4
Bar Pool
4,158
7,329
57%
3
3,943
7,001
56%
3
4,350
7,853
55%
5
983
1,888
52%
13
3,259
5,709
57%
11
Fosse [rural north]
1,939
3,586
54%
9
Wolvey [rural north]
1,139
2,360
48%
9
North Warwickshire - North Locality
North Warwickshire - East Locality
North Warwickshire - West Locality
Nuneaton and Bedworth - Abbey and
Wem Brook Locality
Abbey
Nuneaton and Bedworth - Arbury and
Stockingford Locality
Nuneaton and Bedworth - Camp Hill and
Galley Common Locality
Camp Hill
Nuneaton and Bedworth - Whitestone
and Bulkington Locality
Attleborough
Rugby - Rugby Rural Locality
Leam Valley [rural south]
Dunchurch and Knightlow [rural south]
Rugby - Rugby Town East Locality
33
Hillmorton
2,851
5,084
56%
6
3,286
6,383
51%
4
3,233
5,668
57%
4
3,467
6,977
50%
12
Kinwarton
848
2,055
41%
12
Claverdon
1,258
2,327
54%
11
Welford
1,132
2,055
55%
10
Alcester
3,109
6,014
52%
10
994
1,986
50%
9
Tanworth
2,108
3,859
55%
9
Studley
3,164
5,778
55%
7
Fenny Compton
1,179
2,548
46%
18
Stockton and Napton
1,300
2,587
50%
14
Long Itchington
1,237
2,501
49%
12
Southam
3,774
6,611
57%
11
926
2,018
46%
14
Brailes
1,065
2,077
51%
13
Quinton
1,483
2,655
56%
12
Tredington
1,237
2,335
53%
11
Stratford Avenue and New Town
3,876
7,231
54%
5
Stratford Guild and Hathaway
3,879
7,415
52%
5
Lapworth
1,496
2,915
51%
9
Cubbington
3,361
5,888
57%
6
Milverton
4,711
8,733
54%
4
Manor
4,785
8,307
58%
4
Crown
3,199
5,858
55%
3
Clarendon
2,891
5,210
55%
3
Willes
4,489
9,614
47%
3
Brunswick
4,484
9,902
45%
2
Rugby - Rugby Town North Locality
Benn
Rugby - Rugby Town West Locality
Caldecott
Stratford on Avon - Alcester, Studley &
Henley Locality
Bidford and Salford
Aston Cantlow
Stratford on Avon - Southam,
Wellesbourne & Kineton Locality
Stratford on Avon - Stratford & Shipston
Locality
Long Compton
Warwick - Warwick Rural
Warwick - North Leamington
Warwick - South Leamington & Whitnash
34
5. Conclusion
This needs assessment has shown that there are prevailing oral health inequalities in
Warwickshire with children living in the most deprived areas having poorer outcomes
in terms of dental health. It has also demonstrated that the main factor influencing
access to NHS dentistry is the availability of local services. It has identified areas with
significantly lower access rates than the county average and made
recommendations for the commissioning of dental services in some of these areas.
In interpreting the findings of this needs assessment certain limitations of the process
have to be taken into consideration. There is a lack of epidemiological data on adult
dental health at the local level to inform the needs analysis. The needs of the hard to
reach and vulnerable population are also difficult to quantify due to lack of
epidemiological data. The proposed survey of the oral health needs of care home
residents will hopefully address this information deficit in the future. There is also a
need for a better understanding of local views on dentistry to inform the
development of services that are more appropriate to meet local needs and
improve contact with these services.
Despite these limitations this needs analysis has provided enough evidence to inform
the recommendations for the commissioning of services to improve access to dental
primary care in Warwickshire and contribute to the process of reducing the prevailing
oral health inequalities.
A detailed description of the proposed schemes in terms of the socio-demographic
characteristics of the area and the resources required to meet the identified need
are available in the Memorandum of Information (MOI) document for the
procurement programme.
35
Appendix 1
Appendix 2