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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