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Oral Health for all Northlanders Oranga Mangai mo Te Tai Tokerau A Strategy for Oral Health in Northland Adopted by the Board March 2007 Table of Contents 1 2 3 4 Executive Summary ...................................................................................................................... 1 Why we need an Oral Health Strategy ......................................................................................... 2 Background and Scope of Strategy .............................................................................................. 3 Oral Health Services in New Zealand .......................................................................................... 5 4.1 Service coverage ................................................................................................................. 5 4.2 Health Practitioners Competence Assurance Act 2003 ...................................................... 5 4.3 Publicly funded work in private practice ............................................................................ 6 4.4 Maori Child Oral Health Services Review (MCOH) .......................................................... 6 4.5 School Dental Services Facilities Review .......................................................................... 6 4.6 Future directions ................................................................................................................. 7 5 Oral Health Services in Northland ............................................................................................... 8 5.1 Types of oral health provider .............................................................................................. 8 5.2 The ‘Lifecourse’ approach .................................................................................................. 8 6 Needs analysis ............................................................................................................................ 10 6.1 Early childhood (preschoolers and their mums) ............................................................... 10 6.2 School Aged Children ....................................................................................................... 12 6.3 Adolescents ....................................................................................................................... 16 6.4 Adults ................................................................................................................................ 18 7 Secondary Services ..................................................................................................................... 22 8 Oral Health Promotion ............................................................................................................... 23 8.1 Importance of oral health promotion ................................................................................ 23 8.2 Water Fluoridation ............................................................................................................ 23 8.3 Fluoridation in non-reticulated areas ................................................................................ 24 9 Summary of findings from the Situation Analysis ..................................................................... 25 10 Goals ........................................................................................................................................... 27 10.1 Promote Oral Health ......................................................................................................... 27 10.2 Develop publicly funded dental services and facilities that best meet the needs of Northlanders ...................................................................................................................... 28 10.3 Increase, develop and support the oral health workforce .................................................. 29 10.4 Ensure a quality service .................................................................................................... 29 11 Implementation Plan ................................................................................................................... 31 Appendix 1 Acknowledgements ................................................................................................... 33 Appendix 2 Maori Child Oral Health Services Review Recommendations ................................. 34 Appendix 3 Recommendations from SDS review ........................................................................ 36 Appendix 4 Private Provider Survey Results ............................................................................... 39 Glossary ............................................................................................................................................. 43 References ......................................................................................................................................... 47 TU UT TU TU UT TU TU UT TU TU UT TU TU TU UT UT UT UT TU TU UT TU TU UT TU TU UT TU TU UT TU TU UT TU UT UT UT UT UT UT TU UT UT TU UT TU TU UT TU UT UT TU UT TU TU UT TU TU UT TU TU UT TU TU TU UT TU UT UT TU UT TU UT TU TU TU UT UT UT UT UT UT UT TU UT TU TU UT TU TU UT TU UT UT UT TU UT UT TU UT TU UT TU TU UT TU TU UT TU TU UT TU UT UT TU UT UT UT TU UT TU UT TU TU UT TU TU UT TU TU UT TU TU UT UT UT UT UT TU UT Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Lifecourse approach, service roadblocks, access issues and Northland providers ......... 9 Northland populations by age, 2001 Census and projected for 2006 and 2016 ............ 10 Excerpt from Well-Child Handbook ............................................................................. 11 Location of rural clinics, Northland DHB School Dental Service, October 2006 ........ 13 Number of dental therapists, actual and estimated shortage ......................................... 14 Dentists providing of adult oral health services in Northland, October 2006 ............... 20 TU UT TU TU UT TU TU UT TU TU UT TU TU UT TU TU UT TU UT UT UT UT UT UT 1 Executive Summary The Strategy for Oral Health in Northland has been written to identify the goals that will support the achievement of the vision: Oral Health for all Northlanders Oranga Mangai mo Te Tai Tokerau Within this vision of oral health for all Northlanders, the aim of this strategy is to reduce and eliminate oral health inequalities by achieving four goals: 1 To promote oral health 2 To develop publicly funded oral health services and facilities that best meet the needs of Northlanders 3 To increase, develop and support the oral health workforce 4 To ensure a quality service. The Northland Oral Health Planning Group prepared this strategy during a period of review by the Ministry of Health, to which Northland contributed, and which culminated in the Ministry publishing, in August 2006, a new strategic vision for oral health in New Zealand “Good Oral Health for All, for Life”. This strategy has been written in the context of the vision and to support the achievement of NDHB’s District Strategic Plan 2005-2010 and provides the strategic direction for one of the five strategic priorities, oral health, with a focus on one of the four priority population groups, children and youth. Northland experiences some of the highest dental disease rates in New Zealand. There are inequalities of both oral health status and access to oral health services, particularly for Maori and Pacific people and those living in rural areas and with lower socioeconomic status. None of Northland’s water supplies are fluoridated. To achieve equity of access and oral health outcomes this strategy advocates for an integrated and seamless Northland-wide oral health service, delivered by a mix of providers. This will mainly be achieved by means of oral health teams, consisting of dental therapists and dental assistants, with the support of dentists, working out of community based fixed and mobile facilities. A dental therapist to patient ratio of 1:600 is recommended in order to address the high level of disease among children and youth in the district. Alongside the focus on reconfiguration and reorientation of oral health services in Northland, this strategy places an emphasis on expanding oral health promotion activities and using a variety of approaches to prevent dental decay and gum disease. This document contains a description of current service provision and analyses need based on different populations: pre-schoolers and their mums; school aged children; adolescents; adults. It also looks at secondary services and health promotion. A brief implementation plan is included to identify initial actions that need to be taken to work towards achievement of the goals. Northland Oral Health Strategy, Feb 2007 Page 1 of 47 2 Why we need an Oral Health Strategy Oral health is important: when you have good oral health, you will generally feel good and look good. When you have poor oral health you are likely to experience oral infections, recurrent episodes of pain, general discomfort, eating difficulties and poorer general health and well-being. A mouth that doesn’t look good, due to rotten or missing teeth, can seriously affect your ability to interact socially with friends, peers and work colleagues and can adversely affect educational success and employment opportunities. There is a close link between oral health and general health. The same ‘lifestyle’ risk factors (eg, poor nutrition and diet, smoking, alcohol and a lack of physical activity) that contribute to poor oral health will also increase susceptibility to other chronic diseases such as cardiovascular disease, renal disease, diabetes and obesity. Northland experiences some of the highest dental disease rates in New Zealand. There are also known inequalities in both oral health status and access to oral health services, particularly for Maori and Pacific people and those living in rural and lower socioeconomic areas. One of the principle aims of this strategy, and the objectives and actions that flow from it, is to reduce these inequalities wherever possible. This strategy for improving oral health for all Northlanders will also try to reduce the levels of oral disease currently existing, while seeing an increasing number of Northlanders exhibit functional, pain-free and socially aesthetic dentitions. Northland District Health Board and the New Zealand Ministry of Health have made oral health one of their key health priorities. The ‘Lifecourse’ approach The recent launch of the New Zealand strategic vision for oral health Good Oral Health for Life, for All, has provided the vision and framework on which Northland’s Oral Health Strategy could be developed and realised. The focus of this vision is initially on the younger members of our population (0-17 year group). This supports the sound and evidence-based concept of a ‘lifecourse approach’ to improving health outcomes. This concept is particularly helpful in a limited resource environment such as public health services, where the focus should be on achieving more favourable health outcomes as early as possible in a person’s life. The NDHB oral health strategy supports, in principle, this ‘lifecourse’ approach to the planning and investment in oral health promotion and treatment services. However through the process of investing in oral health facilities and workforce for our youngest members of society, it is recognised that there will be opportunities for improving oral health outcomes and access for other special needs groups such as the elderly, the medically compromised and low-income adults. Working together There is a wide range of providers working in oral health, including private, community, Maori and NDHB. There are also proactive Primary Health Organisations and other agencies, both from the government and non-government sectors, all wanting to see a healthier Northland. There are therefore many opportunities to improve oral health through working together and it is hoped this strategy will play a part in achieving ‘Oral Health for All Northlanders’, as well as improve the general health of individuals. Northland Oral Health Strategy, Feb 2007 Page 2 of 47 3 Background and Scope of Strategy Oral health is considered one of the strategic priorities for the health of New Zealanders as a whole, Maori and Pacific health, and specifically for Northland. This understanding of the importance of oral health has been developed and underpinned by the following national strategy documents and papers: New Zealand Health Strategy Maori Health Strategy Child Health Strategy DHB Toolkit: Improve Oral Health, 2004 Achieving Health for All People: A Framework for Public Health Action for the NZ Health Strategy Primary Health Care Strategy Improving Child Oral Health and Reducing Child Oral Health Inequalities In early 2004 the Northland Oral Health Planning Group (NOHPG) 1 , was brought together with the purpose of developing a Northland Oral Health Strategy for the next 3 to 5 years. TP PT The NOHPG was set up under the auspices of the NDHB’s planning and funding responsibilities, and reported, via the Service Development and Funding (SD&F) team to the General Manager SD&F. The group’s advice and conclusions formed the basis of the oral health component of the District Strategic Plan. The NOHPG in 2004 was initially charged with investigating and detailing the oral health needs and service gaps of the population of Northland and to provide recommendations and actions for better outcomes from, and improved access to, oral health services across Northland. The focus was intended to be on oral health as a primary care issue, rather than at secondary and tertiary levels. More specifically however, the NOHPG was asked to develop a Northland Oral Health Strategy document that would: 1 2 3 4 5 6 Carry out a baseline needs analysis. Investigate options for the delivery of comprehensive, needs based, Northland wide oral health services and make recommendations to the GM SD&F for inclusion in NDHB planning. Undertake a desk top workforce and current services stocktake. Consider workforce recruitment and retention issues. Consider the future of the School Dental Service (SDS) and recommend a response to any planning requests from the National project to the GM SD&F. Consider findings from the SDS Facilities Review and other Ministry of Health documents and reviews. A final draft of the strategy was delivered to the GM SD&F in April 2005. However from this date until June 2006 there was a delay in moving the strategy forward due to developments and specific requests for information from the Ministry of Health. This was in preparation for the launch of a new national strategic vision for oral health by the Ministry of Health in August 2006. From the NDHB perspective this meant preparing and sending off further documents related to Northland’s current oral health facilities and assets and a proposed service plan for an integrated 0-17 oral health service in June 2005. No further work was therefore done on the Northland oral health strategy until after the official launch of the national strategic oral 1 TP PT Refer Appendix 1 for group membership Northland Oral Health Strategy, Feb 2007 Page 3 of 47 health vision Good Oral Health for All, for Life. This Ministry of Health document lays out a clear vision and direction for future public oral health services. It also provides a robust framework on which strategic and operational oral health service development should occur. In the light of the above developments and directives from the Ministry of Health, the Northland Oral Health Planning Group reconvened in August 2006. This was to further progress the Northland Oral Health strategy, with a special focus on embracing the new national oral health vision. This resulted in the Northland Oral Health Strategy in its present form. It, like the national oral health strategic vision, continues to support and promote a more integrated and seamless approach to delivering primary public oral health services. Northland Oral Health Strategy, Feb 2007 Page 4 of 47 4 Oral Health Services in New Zealand 4.1 Service coverage In New Zealand, the focus of publicly funded oral health is on children and adolescents. The intent is that all people up to the age of 18 have the opportunity to receive free oral health care through public dental services. After that age, the general expectation is that adults should take responsibility for their own oral health in the private setting, although public oral health services are available to special needs groups and low-income adults. ‘Essential’ care and ‘relief of pain’ dental treatment is therefore offered to low income adults in some areas, and specialist hospital level care is offered to all New Zealanders as required. Work and Income also contracts oral health providers to provide some limited emergency dental services to low-income adults. However there are a number of issues, which the MoH, DHBs and oral health providers are grappling with, including: • inequalities in oral health outcomes and access, based on ethnicity, rurality, and socioeconomic levels • a shortage of private dental services in rural areas • withdrawal of private providers from public contracts in some areas, leaving gaps in service provision • groups of children, adolescents and adults not receiving oral health care, due to significant barriers to access • all oral health providers facing workforce shortages, non-compliant facilities, and lack of appropriate service models to meet demand On the positive side, many areas in New Zealand now have fluoridated water, which has improved dental decay rates; unfortunately Northland has no fluoride in its water and so does not benefit from this important public dental health measure. 4.2 Health Practitioners Competence Assurance Act 2003 In September 2004 the Health Practitioners Competence Assurance Act 2003 came into effect. All oral health practitioners now work under this act. There are general and additional dental therapist scopes of practice for children, adolescents and adults. This means that dental therapists now have the opportunity to extend basic primary dental care to adolescents and adults. Dental therapists are now independent health practitioners; provided they meet registration requirements, they can work independently of public health providers. They can therefore work in public or private practice, but are required to have a professional mentoring relationship with a dentist of their choice. This professional relationship is probably closer than that which used to be with the Principal Dental Officer of the NDHB, so there is greater opportunity for information sharing and coordination of comprehensive clinical care. Northland Oral Health Strategy, Feb 2007 Page 5 of 47 4.3 Publicly funded work in private practice Publicly funded contracts offered by the DHB to private providers are as follows: • school children (0-12 years) Special Dental Benefits (Section 88); known as SDB, this is for complex cases beyond the scope of practice or experience of a dental therapist • adolescents (13-17 years) General Dental Benefits Contract (Section 88), known as GDB; this contract was phased out in 2005 and replaced with the Oral Health Services Agreement (OHSA), which is the adolescent-specific portion of the combined dental agreement contract • combined SDB and adolescents (13-17 years) Oral Health Services Agreement (OHSA), which started in January 2006. 4.4 Maori Child Oral Health Services Review (MCOH) In 2004 the Ministry of Health commissioned a review of Maori Child Oral Health Services. The aim of the MCOH review was to obtain information about the types of services being delivered, the capacity and capability needs of the services and to identify preferred models of Maori child oral health services. The recommendations of this review are closely aligned to the objectives of this strategy. One key recommendation is that: A coordinated approach to the delivery of oral health services to Maori is crucial and the relationship between DHBs, Maori providers, School Dental Service and dentists must be focused on addressing inequalities in Maori child oral health. A summary of the MCOH recommendations is provided in Appendix 2. 4.5 School Dental Services Facilities Review In 2004 the Ministry of Health required DHBs to survey School Dental Service (SDS) facilities using the stocktake tool developed by the School Dental Services Technical Advisory Group (SDSTAG). Using this information each DHB was to develop a service model that met the needs of its child population most effectively then and in the future. The focus was to be on reducing child oral health inequalities. NDHB reported on: • inequalities • a service reconfiguration plan • consultation feedback • an indication of the proposed implementation outcomes for inclusion in NDHB’s District Annual Plan for 2005/2006. It was found that none of the current fixed SDS clinics met the recommended standards, and the majority of equipment had exceeded its expected lifespan. A possible service model configuration was developed (see Appendix 3), but this was devised prior to the Ministry of Health releasing its national strategic vision for oral health. Northland Oral Health Strategy, Feb 2007 Page 6 of 47 4.6 Future directions In August 2005 the Minister of Health released a statement of the future direction for child and adolescent oral health services, to have these features: • community based dental services with strong links to schools, Maori oral health providers and primary care providers • a seamless 0-17 year old structure, which has the ability to extend to whanau/ adults • delivery through a mix of fixed and mobile facilities that are suitable for modern dentistry • a focus on prevention and very early intervention • an appropriate and skilled workforce • nationally consistent dental data. This was followed a year later in August 2006 by the Ministry of Health’s launch of a new strategic vision for oral health in New Zealand entitled Good Oral Health for All, for Life, with the following seven key action areas: • reorientation of child and adolescent public oral health services • reduce inequalities in oral health outcomes • promote oral health • build the oral health workforce • build links with primary care • develop oral health policy • research, monitoring and evaluation. This new national strategic vision for oral health further supports the vision and objectives of what could be a Northland-wide integrated, seamless, community-based public primary care oral health service. This concept had already been mooted by the NOHPG which had already explored this vision in its draft oral health strategy of 2005. This final document has built upon and reflects this shared vision. Northland Oral Health Strategy, Feb 2007 Page 7 of 47 5 Oral Health Services in Northland 5.1 Types of oral health provider There are two main types of oral health provider in Northland: Private providers run as independent businesses. There are 23 private oral health providers in Northland (excluding orthodontics and denture management) who employ 38 dentists. As of September 2006 only 13 dental practices held contracts for adolescent services, 3 of which also held a contract to provide SDB services. All providers are paid on a fee for services basis. Some providers will only provide adolescent services to the children of their registered adult clients. Community and Maori providers generally have a responsibility for a specific population, community or group, and are funded by a combination of capitation funding and fee-for-service depending on their workforce capacity and the type of services they offer. These oral health providers tend to take the service to the areas of highest need, and invariably deliver services at or close to where patients live or go to school. The community and Maori oral health providers in Northland are Hokianga Health, Hauora Whanui (Ngati Hine Health Trust) and NDHB Public Dental Service. NDHB Public Dental Service also provides the secondary dental care service mainly out of Whangarei Hospital. Increasingly, the focus is moving to adolescent and lowincome adult groups because of the high level of need identified, but limited financial and human resources mean that only some of the gaps in service to these high need groups are addressed. 5.2 The ‘Lifecourse’ approach According to ‘lifecourse’ theories, factors that help or hinder oral health accumulate over time. People are exposed to numerous different factors which can influence oral health at individual, behavioural, socioeconomic, or environmental levels. While the influences of oral health can be felt into old age, there are some critical periods over the lifetime when either beneficial or hindering factors can have the most impact. These are the early years of life, when habits are being formed, and following the eruption of primary, permanent and wisdom teeth, before the enamel hardens. It is also important to ensure adequate education of adolescents because they are the adults and parents of the future. The current oral health system recognises the importance of oral health in childhood and adolescence, but there should be more priority placed on oral health through adulthood and into old age as well. This strategy therefore recommends the adoption of a ‘lifecourse’ approach to managing and resourcing present and future public oral health promotion and treatment services in Northland. Hence, the above age groups have been identified in the assessment of the current oral health needs and services in the next chapter. Figure 1 provides a high-level pictorial representation of the services available by age group, and the related access and tracking issues. Northland Oral Health Strategy, Feb 2007 Page 8 of 47 Figure 1 Lifecourse approach, service roadblocks 2 , access issues and Northland providers TP PT Age 0-5 Roadblocks Key access issues Identification and enrolment 5-12 13-15 Transfer to OHSA scheme 16-17 65+ Transfer to private care Leave school Awareness of service 18-64 Reduced income Limited income Adolescent attitudes Mobility Cost Parental attitudes Awareness of service Compatibility with family Attendance on acute pain rather than regular checkups Service availability and disability access (location, hours, staffing, etc.) Northland providers Private SDB 9 9 OHSA Privately funded Community, Maori Hauora Whanui 9 9 9 9 9 9 9 9 Under SDS 9 Under SDS 9 9 9 Private 9 Private 9 9 9 9 9 9 9 9 9 Low income 9 Low income 9 9 9 9 9 Hokianga Health NDHB 9 9 Community SDB 9 SDB 9 Secondary 9 9 School Dental Service Adolescent 2 TP PT Under the current siloed approach there are various roadblocks that contribute to the discontinuity of services. The transfer of children from the School Dental Service to OHSA, or of adolescents from OHSA to private practice, both contribute to client loss from oral health services. A seamless service would remove some of these roadblocks, thus improving continuity of care. Northland Oral Health Strategy, Feb 2007 Page 9 of 47 6 Needs analysis This strategy divides the population into four age-related groups (preschool 0-4 years, school aged 5-12 years, adolescent 13-17 years, and adult 18 years and over) based on the chronological splits that have historically existed in the way services have been provided. Figure 2 provides summary demographic information for these age groups for 3 different years. Figure 2 Northland populations by age, Census 2001 and 2006 and projected for 2016 Age group Year 2001 Census 2006 Census 2016 projected (2001-base) 0-4 10,476 10,272 8,950 5-12 19,718 19,333 16,980 13-17 10,508 11,516 10,298 18 and over 99,401 107,355 119,532 140,103 148,470 155,760 All ages 2001-base projections suggest that the numbers of 0-17 year olds will decrease over time (from 41,022 in 2006 to 36,228 in 2016). However, because the Maori population’s growth rate is higher than non-Maori, the proportion of Maori in the younger population will increase (from 37% of the child population in 2001 to 41% in 2016). Maori children have higher oral health needs, so it is unlikely that overall oral health needs in children will decrease much in the short term at least. While the needs of children and youth will receive first priority, the data in Figure 2 indicate that the number of adults will be growing significantly over the next decade. Needs of adults, particularly of those aged over 65, the age group that will show the biggest percentage growth, will become increasingly important over time. 6.1 Early childhood (preschoolers and their mums) 6.1.1 Population The 2006 Census counted 10,272 preschoolers in Northland. In 2006 the SDS had 5,198 preschool children enrolled in their service, 51% of the estimated preschool population. During 2005/06 the SDS had completed 3,587 treatments of preschoolers. 6.1.2 Need In an analysis of the hospital events with an oral health related primary diagnosis for the period 2000/05, preschoolers made up 41% of the events while making up only 7% of the population. In 2005/06, 291 pre-schoolers received SDB treatments through NDHB. Research identifies the following as indicators of oral health risk for children: • fluoride availability • socioeconomic status Northland Oral Health Strategy, Feb 2007 Page 10 of 47 • • • • • maternal education (food, behaviour, attendance) maternal oral health (hereditary, behaviour, anxiety) ethnicity locality disability status. Increasingly throughout New Zealand there are oral health initiatives being targeted at pregnant mothers, adolescents and mothers of young children. There are two key factors in targeting mothers: • oral health disease in pregnant mothers can affect the health and oral health of their babies and children • mothers are the predominant providers and teachers of young children. 6.1.3 Services The School Dental Service is primarily responsible for the enrolment and primary treatment of preschoolers. Discussion of the SDS is provided in section 6.2. Oral health in preschoolers is also the responsibility of other health providers and professionals such as: • well-child providers • GPs and PHOs • midwives • Maori health providers. Figure 3 Excerpt from Well-Child Handbook Recommended procedure: Provide care in a culturally appropriate manner Assess family/whanau need for information and support Provide relevant information and anticipatory guidance to parents/caregivers to promote oral health care Identify barriers to access, including historical barriers Check the teeth for abnormalities when they have erupted Facilitate referral of the infant to the dental therapist from 12 months of age Document findings and health gains identified including in the Well ChildTamariki Ora Health Book Use appropriate referral pathway. Educational preparation needs to include: Oral hygiene Age-appropriate nutrition Normal and abnormal teeth and mouths Appropriate use of feeding bottle. Hauora Whanui is the only provider with a contract that focuses on pregnant mothers and mothers of young children. However, the contract is only to provide dental examinations and clean teeth. Any other requirements have to be referred to a dentist, which could be a barrier to accessing necessary care. Northland Oral Health Strategy, Feb 2007 Page 11 of 47 6.1.4 Summary of Issues Enrolment and treatment of preschoolers requires attention from of all health providers. There is an opportunity to increase the focus of well-child providers on oral health promotion and enrolling preschoolers in SDS. There is an opportunity to include oral health messages and basic oral examinations at the standard health checks for pregnant mothers and mothers with preschool children. All of the issues identified in section 6.2 relating to school children are relevant to preschoolers. Further work needs to be done on considering the options of full, community based services that could cater to all age groups. Appropriateness of service is extremely important for this group because it sets them up for involvement in the service throughout life. 6.2 School Aged Children 6.2.1 Population According to the June 2006 school rolls there were 19,744 school children (aged 5-12, or year 1-8) in Northland. In 2006 the SDS had 17,917 school children enrolled in their service, so 91% of all school children were enrolled. During 2005/06 the School Dental Service (SDS) had 25,140 attendances. 11,622 children completed their course of treatment, 3,587 of whom were preschoolers, and 8,035 were school children. The actual number of treatments by SDS was 67,073 for both pre-school and school-age children. 6.2.2 Need A national comparison in 2004 found Northland DHB out of all the DHBs had the worst caries-free figure at 33% and the worst 5 year age DMFT (decayed missing and filled permanent teeth) at 4.11. The average DMFT for the whole of New Zealand was 2.11, and 2.56 for non-fluoridated areas. The New Zealand average caries-free rate was 52% total and 45% for non-fluoridated areas. 31% of Northland hospital events over the last 5 years with an oral-health-related primary diagnosis were school children, though they are only 18% of the Northland population. Maori and Pacific children are disadvantaged compared with the rest of the population: only 14% of Maori and 25% of Pacific 5-year-olds were caries-free in 2005, compared with 48% of other ethnicities. In addition, the percentages for Maori and Pacific children have been trending down over the last few years. 6.2.3 Services Figure 4 shows the extensive coverage achieved by the School Dental Service. This structure helps the service gain access to schoolchildren, but its capital-intensive nature, with many school-based clinics scattered throughout Northland, makes it expensive to maintain. Northland Oral Health Strategy, Feb 2007 Page 12 of 47 Figure 4 Location of rural clinics, Northland DHB School Dental Service, October 2006 Northland Oral Health Strategy, Feb 2007 Page 13 of 47 The NDHB Public Dental Service presently has responsibility for offering oral health treatment services for children up to the age of 12 years. Dental therapists, supported by assistants, provide basic preventive and restorative care. If children require more complex treatment they are referred to private dental practitioners contracted under special dental benefits (SDB), or community dentists working within the NDHB Public Dental Service. Hauora Whanui provides some care for children in their local Kura Kaupapa Maori schools on behalf of NDHB Public Dental Service. Their numbers are included in the analysis of the SDS. In the SDS review a decision tree (Appendix 3) was developed to weight schools for need based on DMFT figures and school deciles. This suggested a shortage of 13.5 therapist teams, much more than the 4.5 dental therapist/assistant teams suggested by the commonly used national ratio of 1:1,100. Due to the shortage of therapists not all children are being seen 12-monthly. Particular gaps are in the Mid North and Far North regions. Figure 5 shows actual numbers of therapists and the results of applying the two different needs assessment tools by area within Northland. Figure 5 Number of dental therapists, actual and estimated shortage Number of dental therapists 2004 (FTEs) Estimated total based on 1:1,000 Estimated total based on NOHPG needs analysis Far North 4.5 4.0 5.5 Whangaroa 1.0 1.0 1.0 Hokianga 1.0 1.0 1.75 BOI 2.0 6.0 7.0 Urban Whangarei 8.0 10.0 13.25 Rural Whangarei 4.0 4.0 4.0 Kaipara 3.0 3.0 4.5 23.5 28.0 37.0 Total Northland There is a shortage of private dentists who will accept SDB referrals. Three dental practices hold contracts for SDB services. Anecdotally, it is understood that it is difficult to find dentists who will take private paying children. NDHB provides a dentist based with their north team to do SDB work. NDHB Public Dental Service community dentists now do most of the more complex work referred on by dental therapists. This is done in the dental suite at Whangarei Hospital, in the SDS school clinics throughout the region and the surgical bus. In 2005/06, 1,162 children were treated under the SDB scheme, 209 of whom were treated in the surgical bus. Northland Oral Health Strategy, Feb 2007 Page 14 of 47 The recent SDS review identified the following issues relating to school-aged service provision: Access Parents sometimes don’t know when the mobile unit will be in their schools (they are told, but sometimes don’t remember). If the fixed clinic is closed, parents sometimes don’t think about going anywhere else. Children from some smaller schools have to travel to other schools for care. Mobile units do not visit any early childhood centres, doctors’ practices or marae. Some schools are difficult to take services to, especially in getting access for mobiles. Service barriers Lack of therapists means that children don’t get seen often enough and problems compound. The service has been run in the same way for many years and it may be difficult to change from the national structure. The service has reduced over time, and there isn’t a full-time therapist in each clinic anymore. Does the funding formula reflect the high needs in Northland? Socioeconomic barriers Economic fluctuations mean people move from Northland to Auckland to find work. Transport. Education on prevention. Mothers’ perceptions of need for oral health. Cost of toothpaste etc. Transience Don’t attend appointments. Difficulty keeping track of children. Difficulty getting consent for treatment. Children move in and out of Northland, particularly to South Auckland. Cultural barriers Only a small number of therapists and assistants are Maori. Must respect concept of tapu of the body. 6.2.4 Summary of Issues The SDS does not have the human and financial resource capacity to meet the high oral health needs of all children in Northland. Not all private providers will take on private paying child patients. There is a shortage of dentists to be SDB providers of child and adolescent dental care. Northland Oral Health Strategy, Feb 2007 Page 15 of 47 6.3 Adolescents 6.3.1 Population MoH describes the adolescent population for oral health as being those aged between 13 and 17 inclusive (that is, up to but not including the eighteenth birthday). The 2006 Census recorded 11,516 people aged between 13 and 17 years inclusive in Northland. During 2003/04 5,588 (49% 3 ) had completed treatments, leaving a gap of 5,712 (51%) adolescents with either no treatment, partial treatment, or paying for their care privately. The MoH aims for 85% coverage. TP PT Since 2003/04 the number of private dental providers signed up to adolescent dental contracts within Northland has decreased from 23 to 13. Of the 13 private providers remaining, only one is located outside of Whangarei. This has meant an ever-decreasing level of accessible oral health services for adolescents living in rural areas; this group, because of the difficulty it has in accessing services and its ethnicity and deprivation, is our most needy. Adolescent service contracts are increasingly seen as being unattractive to private dental providers, and evidence to date has shown that once providers exit from this contract they are unlikely to resign. 6.3.2 Need There is very little information collected on the needs of adolescents. The 12-year-old DMFT rate is 2.6. However, there is concern that this number doesn’t represent the true picture due to some areas, especially those with higher needs, not having any access to services. This is reflected in figures which show that the areas with highest DMFT rates are the more rural, high-deprivation areas that include Whangaroa (3.8), Hokianga (3.2) and Bay of Islands (3.1). The Far North has a 12-year-old DMFT rate of 1.9, which seems low and is probably not accurate. Maori adolescents have poorer oral health than their European counterparts. In 2002, the DMFT score for Maori was 2.9, compared to 1.5 for European/other 4 . 2004 data suggests the Maori figure has worsened slightly to 3.0 5 . The picture is the same for 12-year-olds: in 2005, 41% of non-Maori/non-Pacific were caries-free, but only 24% of Maori and 10% of Pacific children were caries-free. The caries-free percentage for this age group has generally decreased over the last few years 6 . TP TP TP PT PT PT Oral health planning must take account of the projected increase in the number of Maori children and adolescents in Northland. By 2016 the percentage of Maori in the 0-24 age group will increase to 41% of the child and youth population, from 37% in 2001. Overall, the 0-24 population is projected to decrease by 8.3% between 2006 and 2016, a numerical drop of 4,320. 3 TP PT 4 TP PT 5 TP PT 6 TP PT Based on the 2001-based projection that estimated the population of 13-17yr olds to be 11,300. Paediatric Society Report to NDHB, 2005. Community Dental Service, NDHB. NDHB data from School Dental Service for 1994-2005. Northland Oral Health Strategy, Feb 2007 Page 16 of 47 6.3.3 Services When adolescents go to secondary school they should be offered the opportunity to enrol with a public adolescent provider to continue to receive free care until they turn 18. Many adolescents however haven’t been receiving treatment so public sector providers have recently undertaken access and service initiatives to try and fill the gap. The service coverage across Northland is however sporadic at best and non-existent at worst. NDHB’s Public Dental Service runs two mobile dental units dedicated to adolescent care. Adolescent South covers Whangarei and Kaipara and Adolescent North covers Whangaroa, Taipa and Kaitaia. As part of the strategy development, a questionnaire was sent to all private providers in Northland. Full results are provided in Appendix 4; some key points: • some dentists limit their adolescent numbers to children of existing patients • more than 50% of private dentists planned to exit the service within the next 3 years • the key areas identified for DHB support were improving the handover from SDS and promotion of the adolescent service • there were many reasons for not holding a contract; all said it was uneconomic, bureaucratic, and clinically restrictive; other comments were about non-attendance of children, and issues with policies Of particular concern was that three private providers, covering a total of 945 completions, indicated in the survey that they intended to continue providing the service for less than a year. One of those who offered a service 2003/04 (170 completions) had already withdrawn. Hokianga Health, which works out of the SDS clinics at various schools, holds the contract to provide adolescent care in their region. Hauora Whanui is contracted to provide adolescent care within the high schools in Kawakawa and Kaikohe. They have a mobile unit which can be taken on to school grounds. 6.3.4 Summary of Issues There is very little information on the current oral health levels of adolescents. About half the estimated number of adolescents received completed treatments in 2003/04. Private providers are unhappy with the current contracting arrangements. Many are considering withdrawing, or have already withdrawn from offering the adolescent service. Given that they historically provided most of the service, it is important to address this issue. The areas of highest need, based on ethnicity and socioeconomic level, tend to have the lowest private provider coverage. Services need to be specifically targeted to the needs and expectations of adolescents. Northland Oral Health Strategy, Feb 2007 Page 17 of 47 6.4 Adults 6.4.1 Population The 2006 Census counted 107,355 Northland residents aged 18 years and over. 6.4.2 Need There is no information available on the level of need of adults. The majority of care is provided in a private setting and getting detailed information is difficult. Traditionally the focus of the Ministry of Health has been on children and adolescents. Most adults are expected to access private services, but many barriers, particularly financial, exist to gaining access to these services. As a result, certain groups have not been accessing oral health care. There is no information on the number of adults not receiving care, but it is believed to be quite high. Maori made up 56% of all hospital events, compared with their 30% share of the total Northland population. Based on ethnicity and socioeconomic level, all areas within Northland have quite large highneed populations. However, there are only services for low-income adults in Whangarei (by NDHB), Hokianga (by Hokianga Health) and Kawakawa (by Haoura Whanui). Work and Income treatments are discussed below. Based on the lifecourse approach it would make sense to focus on young adults. Catching decay early and developing good habits will provide a basis for improved oral health throughout adulthood. This group of the population are also future parents of children so it is important that they have the knowledge required to educate their children about oral health. It is possible that young adults find it harder to access care due to the financial impact of activities such as undertaking education, having children, and setting up first homes. Older adults, because of the combined effects of age and accumulation of chronic diseases, are another target group. They also suffer increased barriers to accessing care due to factors such as the financial impact of reducing paid work, mobility and medical problems. There are no oral health services targeted at older adults, other than those with multiple morbidities who can access a limited service at Whangarei Hospital. There were a projected 21,930 people aged 65 or over in 2006. As already mentioned, the focus for public funding of oral health is mainly on children and adolescents. There is very limited NDHB funding for special needs groups and low-income adult care. Available services for adults fall into five areas: Private For the majority of adults, services are through private providers on a user pays basis. Relief of pain There is a relief of pain service for low-income adults offered through NDHB’s Community Dental Service, though it runs only in Whangarei. The service’s 2 dentist FTEs also provide other public dental services for children and special needs groups. In 2003/04 they had 1,327 low income completions funded by NDHB and 1,429 completions funded by Work and Income. In 2005/06, 1,675 Community Service Card patients were treated. Hauora Northland Oral Health Strategy, Feb 2007 Page 18 of 47 Whanui also provides Work and Income-funded services for low income adults. Hokianga Health Hokianga Health is contracted to provide primary care oral health services for low income adults in their region, however they extend the service to all registered patients. Work and Income Work and Income contracts providers to undertake care for beneficiaries. They will pay up to $300 a year per client for emergency dental treatment. This usually amounts to at least $500,000 a year, with services going to more than 2000 clients. They also provide advance loans on benefits for at least 800 people to access further emergency treatment beyond the $300 threshold. All funding is for emergency dental treatment only and generally does not render a patient dentally fit. Secondary services Secondary care level services are offered through the hospital oral health service. Adults made up 21% of the hospital events between 2000 and 2005. Further discussion on secondary care services is provided in section 7. Risk factors for oral health are often the same as those for many other health and social issues. There are opportunities to work more closely with organisations such as Work and Income, ACC, local councils and PHOs to try and make a difference in the overall health and living conditions of high need adults. 6.4.3 Services Figure 6 shows that dentists tend to concentrate in the more urbanised areas, especially Whangarei. Northland Oral Health Strategy, Feb 2007 Page 19 of 47 Figure 6 Dentists providing of adult oral health services in Northland, October 2006 Northland Oral Health Strategy, Feb 2007 Page 20 of 47 6.4.4 Summary of Issues Public funding for adult services is extremely limited. Given that there is an emphasis on providing care for the 0-17 year age group adult oral health at present is not seen as a priority for the MoH for the foreseeable future. There is a lack of information regarding oral health needs of adults. Oral health services for low income adults are limited. Work and Income provides funding for oral health services, but only for low-income earners needing emergency care. People aged over 65 years have increasing oral health needs, but there is no monitoring of need, or targeted services. Many of the risk factors for oral health are the same as for other health and social issues. Northland Oral Health Strategy, Feb 2007 Page 21 of 47 7 Secondary Services Hospital-based dental services are available to the whole of the population in Northland. MoH’s service specifications for hospital dentistry indicate that as a minimum all regions should provide the following: • dental services which are an essential part of inpatient hospital medical or surgical treatment • dental services that require hospital admission, such as services requiring general anaesthetic • general and specialist dental services for persons needing special care because of medical conditions or disabilities • general and specialist dental services for persons with severe dental conditions which cannot be treated appropriately in private dental practice. The current hospital dental service in Northland is at an embryonic stage and relatively small, and is staffed by one hospital dental specialist, one day a week. There is a partial on-call service for out-of-hours emergencies. Occasionally there are visiting specialists in oral/maxillo-facial surgery and orthodontics. A recently opened hospital dental suite may allow for further development and enhancement of the existing service in the years to come. Any patients requiring more specialist advice and treatment are referred to the Auckland Regional Oral Health Service, which is the tertiary facility responsible for Northland patients. Some general dentistry that requires a hospital admission, especially for children and adolescents who require a general anaesthetic (GA), is carried out by one of the community dentists employed by NDHB’s Public Dental Service. Most of these GA sessions take place at Whangarei Hospital and a few patients will be seen and treated at Kaitaia Hospital as of February 2007. Increasingly efficient and effective use is being made of the Mobile Surgical Bus that provides a GA facility for medically fit child and adolescent patients who require general dental treatment in the more rural locations of Kaikohe and Dargaville. This facility now treats 50% of the total number of dental treatments (approx. 250) completed under GA each year. The Community Dental Service’s main role is to provide a primary dental care service to: • eligible low-income adults requiring emergency treatment • children and adolescents who require advice, assessment or treatment beyond the scope of practice or experience of a dental therapist (under SDB, OHSA and ACC contracts). The main base for these activities is now at the hospital dental suite in Whangarei. This provides opportunities for community dentists to see and treat some patients who might be considered to lie within the definitions of the hospital dental service specification document. There are therefore some overlaps between primary and secondary care when treatment is carried out within a hospital setting; these might include: • patients requiring basic or general dental care who are medically compromised • patients who require basic or general dental care under general anaesthesia or sedation. There were 566 inpatient hospital attendances in 2003/04; 270 were technically classed as hospital events, meaning that they were admitted for longer than 3 hours and had a primary diagnosis that was oral health related. An analysis of the 1,016 hospital events over a 5 year was undertaken and findings are discussed in relevant sections of this document. Northland Oral Health Strategy, Feb 2007 Page 22 of 47 8 Oral Health Promotion 8.1 Importance of oral health promotion Oral health promotion is one of the key issues for strategic planning. The only way to improve oral health disease levels in Northland is to shift our focus from treatment to prevention. There are 1.4 FTE oral health promoters employed by Northland DHB; 0.8 FTE has a focus on fluoridation advocacy Northland-wide, and the other 0.6 FTE covers general oral health promotion. Hokianga Health undertakes oral health promotion as part of their other health initiatives, but they are not funded specifically for oral health promotion. Hauora Whanui has 1.6 FTE working in oral health promotion who are predominantly involved in the brush-in programmes in local schools. There has been no review of the effects of the brush-in programmes, though anecdotally they are believed to make a difference. Te Hauora O Te Hiku O Te Ika (a Far North iwi provider) also provides some oral health education as part of their well-child services. Many risk factors for oral health are consistent with those for key chronic diseases that PHOs are addressing. There is an opportunity to work with the PHOs and introduce an oral health component into their education initiatives. It is understood that Te Tai Tokerau PHO is already encouraging GPs to look in their patients’ mouths when they come in for general care and Manaia PHO is also introducing oral health promotion in the practices. NDHB therefore has an opportunity to ensure that oral health is a priority within the regional plan for PHOs. 8.2 Water Fluoridation Northland is one of the few regions in New Zealand that has no fluoridation in any of its reticulated water supplies. Water fluoridation is a well proven public health measure that reduces tooth decay rates especially for those who are in the lower socioeconomic groups. Northland DHB employs a fluoride advocate, whose task is to work with the three district councils (Whangarei, Far North and Kaipara) and their communities to encourage discussion and implementation of fluoridation into water supplies. MoH subsidises up to 100% of the costs of setting up water fluoridation so cost is not an argument against it. The councils are required to develop Long Term Council Community Plans (LTCCPs) within which they must detail how they are adding to the health and wellbeing of their communities. Fluoridation would be a measurable factor to be introduced into such plans, which is one of the main tasks of the fluoride advocate. It is estimated that 20,356 children (77%) in Northland attend schools with reticulated water. Fluoridated water would reduce dental decay rates by 40-60% in children and by 10-20% in adults. Based on the SDS decision analysis tree there is a weighted need of 28 therapist/ assistant teams for Northland. Research suggests that if water fluoridation were introduced, over time the level of need for dental therapists and assistants would drop by 40-60%. However, it is unlikely there will be any significant reduction in the primary dental care workload of dental therapists for some time, as the re-establishment of an annual examination for all children in the SDS would need to be achieved first. This could take some time (10 years plus at least) even in the favourable environment of water fluoridation. The future workforce predictions of needing another 12 to 13 therapist teams would therefore stand true for at least the next decade. Northland Oral Health Strategy, Feb 2007 Page 23 of 47 There is a need for all health workers to raise the profile of oral health, and in particular the benefits of fluoridation, so that communities have the information they need to make informed decisions and hopefully lobby councils for water fluoridation. The Far North District Council decided in July 2006 to introduce fluoridated water into two towns in the Mid North and Far North, namely Kaikohe and Kaitaia. This would allow over 10,000 people to access fluoridated water supplies from early 2007. It is an encouraging step in the right direction but extending fluoridation to other parts of Northland may be difficult because of strong and vocal opposition from a small minority within the community. 8.3 Fluoridation in non-reticulated areas While water fluoridation is the most effective way of improving oral health, there are large areas of Northland that are not on reticulated water supplies. The next best way to expose people to fluoride is through regular and daily use of standard strength toothpaste of 1000ppm of fluoride. There is also the option of promoting the benefit to families of making up drinking water themselves to optimal levels of fluoridation (by dissolving two 0.5mg fluoride tablets in 1 litre of water). Northland Oral Health Strategy, Feb 2007 Page 24 of 47 9 Summary of findings from the Situation Analysis Oral health need: The oral health status of 5- and 12-year-olds is worsening. 85% of Northland’s child and youth population live in areas with the lowest 5 deciles (the NZ figure is 56%). There are significant inequalities for Maori and Pacific children and youth. The number of Maori children and youth is projected to rise over the next 10 years. There is inadequate information available about the oral health of adolescents and adults. Early childhood: Enrolment and treatment of preschoolers requires attention from all health providers. There is an opportunity to increase the focus of well-child providers on oral health promotion and enrolling preschoolers in SDS. There is an opportunity to include oral health messages and basic oral examinations at the standard health checks for pregnant mothers and mothers with preschool children. All of the issues relating to school children are relevant to preschoolers. Further work needs to be done on considering the options of full, community-based services that could cater to all age groups. Appropriateness of service is extremely important for this group because it sets them up for involvement in services throughout life. School-aged children: The SDS does not have the human and financial resource capacity to meet the high oral health needs of all children in Northland. Not all private providers will take on private paying child patients. There is a shortage of dentists to be SDB providers of child and adolescent dental care. Adolescents: There is very little information on the current oral health levels of adolescents. About half the estimated number of adolescents received completed treatments in 2003/04. Private providers are unhappy with the current contracting arrangements. Many are considering withdrawing, or have already withdrawn from offering the adolescent service. Given that they historically provided most of the service, it is important to address this issue. The areas of highest need, based on ethnicity and socioeconomic level, tend to have the lowest private provider coverage. Services need to be specifically targeted to the needs and expectations of adolescents. Northland Oral Health Strategy, Feb 2007 Page 25 of 47 Adults: Public funding for adult services is extremely limited. Given that there is an emphasis on providing care for the 0-17 year age group, adult oral health at present is not seen as a priority for the MoH for the foreseeable future. There is a lack of information regarding oral health needs of adults. Oral health services for low income adults are limited. Work and Income provides funding for oral health services, but only for low-income earners needing emergency care. People aged over 65 years have increasing oral health needs, but there is no monitoring of need, or targeted services. Many of the risk factors for oral health are the same as for other health and social issues. Local services around Northland: They vary by locality, particularly among private providers with contracts to look after adolescents and adults. Hokianga Health and the Ngati Hine Health Trust both have contracts to provide some services. Whangarei people have access to the community dental services based at the hospital. Secondary services: There is a small hospital dental service based in Whangarei and Kaitaia hospitals but the mobile surgical bus is also used. Oral health promotion: Contracts for promotion are with NDHB (includes fluoridation advocacy), Hokianga Health, Hauora Whanui and Te Hauora o te Hiku o te Ika; other providers such as Plunket carry out oral health promotion. There is potential to introduce oral health in to PHO initiatives. There is no fluoridation of water systems in Northland, though trials are to be introduced in Kaitaia and Kaikohe. Northland Oral Health Strategy, Feb 2007 Page 26 of 47 10 Goals Within the vision of oral health for all Northlanders, the aim of this strategy is to reduce and eliminate oral health inequalities by achieving four goals: 1 To promote oral health. 2 To develop publicly funded oral health services and facilities that best meet the needs of Northlanders. 3 To increase, develop and support the oral health workforce. 4 To ensure a quality service. Inequalities in oral health exist, both in oral health outcomes and access to services. These inequalities tend to be based on ethnicity (Maori and Pacific people are generally more disadvantaged), rurality, and socioeconomic factors. This strategy, through a combination of oral health promotion, preventive strategies and the reconfiguration and reorientation of Northland’s public oral health services, aims to address these inequalities. Public oral health services could look very different in the years to come, with a number of different models of service delivery operating across the region. However all public oral health services in Northland will have common threads regarding: • maintaining and improving oral health outcomes • providing equitable access to treatment and promotion services • meeting the needs of our local community, in the context of ‘Oral Health for all Northlanders’. In order to maintain equity of access and oral health outcomes, this oral health strategy advocates for the building of an integrated and seamless Northland-wide public oral health service. This will mainly be achieved by means of oral health teams (consisting of dental therapists, dentists, dental assistants etc) working primarily out of community-based fixed and mobile facilities. Dental therapists and assistants will continue to visit areas of Northland that are outlying, rural and of greater socioeconomic deprivation, to support equity of access to basic oral health care for children and adolescents. However in the more urban and highly populated areas there may be slightly different and more complex service models, with a particular focus on encouraging private dental practitioners to be part of the local public oral health team wherever possible. 10.1 Promote Oral Health There is now recognition within society that ‘health is everybody’s business’, and that intersectoral collaboration between health agencies, national and local government, nongovernment agencies and community groups is essential for the promotion of healthy lifestyles for all. Maintaining and improving oral health can only occur if there is a shift of focus and resources (or additional resources are allocated) away from treating oral disease to pursuing health promotion activities and other interventions that might prevent disease. Northland Oral Health Strategy, Feb 2007 Page 27 of 47 Most dental decay and gum disease is preventable, but to make any inroads into reducing the oral disease burdens of our community there must be an oral health promotion strategy that addresses the complexity of oral health issues and is sustainable over several decades. There should be a special focus on families with preschool children to reduce disease levels or more preferably prevent disease altogether. Oral health and general health promotion should occur at every level and strata of our society and include a variety of approaches and interventions at a whole population, community, Whanau and individual level. The promotion of oral health in Northland will therefore mainly be delivered within this ‘intersectoral’ context, so that most oral health promotion will occur outside oral health services per se, by other agencies and health professionals. That aside, there will still be the need for specifically targeted oral health promotion and education activities by oral health personnel, as well the ongoing advocacy of specific oral health population and community based strategies like the fluoridation of reticulated water supplies and school toothbrushing programmes. A Northland-wide oral health promotion plan will be drawn up which will be delivered and supported by an increased number of oral health promotion personnel. A Northland-wide oral health promotion coordinator would oversee this work to ensure that consistency of messages and approach is being maintained across the region. 10.2 Develop publicly funded dental services and facilities that best meet the needs of Northlanders This strategy advocates for the development of an integrated and seamless Northland-wide primary public oral health service that allows for equitable access and oral health outcomes. There will be a particular focus on child and adolescent services to ensure continuity of care can be offered to all patients from birth through to adulthood. In some areas of very high need, there will be also the opportunity to offer additional services to low-income and special needs adults, and some of these services will have a strong ‘Whanau Ora’ approach to delivering oral health care. Therefore the models of service delivery may differ from community to community throughout Northland, but one principle will remain: the ability to deliver comprehensive primary dental care through oral health teams, consisting of a skill-mix of dental professionals (dental therapists, dentists, hygienists etc) at or close to where patients live, work or go to school. This strategy supports the delivery of oral health services throughout Northland to be mainly delivered by way of a simple ‘hub’ and ‘spoke’ model. The ‘hubs’ will consist of modern multi-chair fixed facilities that will: • provide a facility where oral health teams work together to provide quality comprehensive oral health care to all eligible patients (the hubs) • provide a base from which outlying treatment services (the spokes) can be planned and implemented • provide an administrative and team base for all oral health personnel working within the local vicinity. Northland Oral Health Strategy, Feb 2007 Page 28 of 47 The number and types of spokes will look different for each hub. However they will consist of mobile dental facilities in more rural and sparsely populated areas, and a mixture of mobile and fixed facilities in some higher need and/or more highly populated areas. Each oral health provider will work in collaboration and cooperation with other providers to ensure and enhance the building of an integrated and seamless service throughout Northland. All oral health providers will establish close relational and referral links with their neighbouring areas and with Northland’s secondary dental care services to promote a seamless primary-secondary care interface. 10.3 Increase, develop and support the oral health workforce The public oral health workforce is changing. While dental therapists will remain the backbone of the public oral health workforce, there clearly is a need for dentists and other oral health personnel such as hygienists and dental technicians to be involved, in order to deliver a comprehensive primary oral health care service. There is a nationwide shortage of dental therapists and a problem attracting oral health personnel to work in the more rural and inaccessible parts of Northland. The high disease levels presently being experienced in Northland indicate that public dental services in Northland should have a much higher therapist/patient ratio than the national average. Therefore more dental therapist teams will be required to support this new vision. There is also a shortage of dentists across the region, with a decreasing number of dentists showing interest in providing publicly funded dentistry. This strategy therefore requires the implementation of a variety of workforce initiatives that will attract high quality oral health professionals to live and work in Northland. Providing a professionally supportive workplace that means oral health professionals want to stay underpins this approach. Particular emphasis will be placed on increasing the numbers of Maori and Pacific health professionals who are presently under-represented in the clinical workforce. 10.4 Ensure a quality service The future publicly funded oral health service of Northland will maintain and continually improve the quality of its clinical care and services. Northland’s oral health providers and promoters will embrace the concept of ‘clinical governance’, a quality framework within which clinical excellence can flourish. Clinical governance involves every facet of an organisation that works effectively to ensure that its structures, processes and strategic and operational decision-making fully support the delivery of appropriate, accessible and evidence-based clinical care. Quality should encompass all aspects of the planning and delivery of oral health care: what we do; how we do it; where we do it; when we do it; why we do it. There will be a special focus on the provision of oral health services that are accessible, appropriate, patient-focused, evidence-based and treatment that has a predictable and successful outcome. There will be a need to develop standardised quality measures and monitoring processes for all oral health providers across Northland. Northland Oral Health Strategy, Feb 2007 Page 29 of 47 As part of the clinical governance quality framework appropriate research and surveys will be encouraged and carried out within, across and throughout Northland’s public oral health service. This will promote quality clinical care and confirm that it is being delivered. In addition, appropriate monitoring of clinical care outcomes and patient’s/parent’s opinions of the public oral health service will continue to be sought and recorded. Some new indicators of oral health status will be added to enhance the information available for needs analysis and ongoing monitoring of treatment and service outcomes. Northland Oral Health Strategy, Feb 2007 Page 30 of 47 11 Implementation Plan Within the vision of “Oral health for all Northlanders”, the aim of this strategy is to reduce and eliminate oral health inequalities by working towards a set of four goals. This section identifies the key actions to be taken for each of the goals. The priority action, at the time of writing, is to prepare and submit business cases to the Ministry of Health (goal 2.2); this will require work to be completed on the service configuration and team model (2.1) and preparation of a workforce plan (3.1). After this work is completed, the other actions can be prioritised and addressed. Goal 1 Promote oral health Key Action Measure Agencies 1.1 Prepare an oral health promotion plan Plan in place with focus on pre-schoolers and appropriate strategies for Maori NDHB MAPOs PHOs 1.2 Appoint an oral health promotion coordinator Appointment made NDHB 1.3 Continue fluoridation advocacy campaign All 3 District Councils fluoridate their water supplies. NDHB MAPOs TAs Solutions taken up to add fluoride to non-reticulated supplies. Goal 2 Develop publicly funded oral health services and facilities that best meet the needs of Northlanders Key Action Measure Agencies 2.1 Establish a Northland-wide service configuration for 0-17 year olds, using “hubs and spokes” and an oral health team approach adapted to the needs and characteristics of each area. Seamless and integrated configuration developed for 0-17 year olds, with a whanau ora approach where appropriate. 2.2 Prepare and submit business cases to MoH. Submitted business cases are successful NDHB MAPOs PHOs Private dentists PCOs NGOs NDHB MAPOs Goal 3 Increase, develop and support the oral health workforce Key Action 3.1 Prepare workforce plan, with a focus on developing the Maori workforce Northland Oral Health Strategy, Feb 2007 Measure Agencies Plan completed and available for use in business cases NDHB MAPOs PHOs Private Page 31 of 47 Numbers of Northlanders in training increases dentists PCOs NGOs NDHB MAPOs Measure Agencies 4.1 Implement clinical governance quality framework Seminars and training held on clinical governance standards; framework in place, in use and monitored. 4.2 Develop standardised quality measures and monitoring processes Oral health outcomes and disease status indicators agreed and monitored 4.3 Carry out research Research committee in place to overview, encourage and support research NDHB MAPOs PHOs Private dentists PCOs NGOs NDHB MAPOs PHOs Private dentists PCOs NGOs NDHB MAPOs PHOs Private dentists PCOs NGOs 3.2 Provide scholarships Goal 4 Ensure a quality service Key Action Northland Oral Health Strategy, Feb 2007 Page 32 of 47 Appendix 1 Acknowledgements This report has been made possible by the generous contributions of time and expertise by the Northland Oral Health Planning Group by: NDHB Service Development and Funding team representatives Te Tai Tokerau MAPO representative Northern DHB Support Agency representative(s) Oral Health Advisor, Northland District Health Board Hauora Whanui Oral Health Service (Ngati Hine Health) representatives Chief Executive, Hokianga Health Primary Health Organisation (who also provided a communication link with PHO Managers group) NDHB Public Dental Service representatives New Zealand Dental Association (NZDA) Northland Branch representative New Zealand Dental Therapist Association (NZDTA), Northland Branch representative Peer reviewers of the April 2005 draft: John Dalton, Dental Officer, Waitemata DHB Sue Dashfield, Programme Manager Primary Care, Counties Manukau DHB Callum Durwood, Paediatric Dentist, Auckland DHB Pauline Koopu, Advisor Clinical Services Improvement, Ministry of Health Northland Oral Health Strategy, Feb 2007 Page 33 of 47 Appendix 2 Maori Child Oral Health Services Review 7 Recommendations TP PT 1 Maori providers should have flexible oral health service contracts that are funded appropriately to ensure that they can provide necessary services to Maori by adopting a whanau ora approach. More urgently, Maori providers who are providing services outside of their contracts should be reimbursed for the additional services. 2 DHBs should consider capitation funding for Maori provider child oral health contracts so that service can be delivered in the most effective manner. 3 Maori providers recommend increasing the number of oral health community clinics that are based on the successful service at Te Taiwhenua o Heretaunga. Such a service adopts whanau ora as its kaupapa and has proven to reduce the barriers to Maori receiving oral health treatment and therefore reducing inequalities in Maori oral health. 4 Mobile services are considered an essential part of the ideal community service model and funding for this should be prioritised by the Ministry of Health and DHBs in building the capacity of capability of Maori providers. 5 A coordinated approach to the delivery of oral health services to Maori is crucial and the relationship between DHBs, Maori providers, SDS and dentists must be focused on addressing inequalities in Maori child oral health. Coordination plans should be developed that ensures a partnership approach is adopted and the key role of the Maori provider recognised in providing the two key components of any Maori oral health service, being enrolment and attendance. Many other Maori providers are available to offer these services through their tamariki ora nurses and therefore the successful models can be easily duplicated. 6 The Te Taiwhenua o Heretaunga oranga niho service should be developed further into a centre-of-excellence for Maori oral health service. This service would then act as a development site for new initiatives seeking successful approaches and outcomes to improve the status of Maori oral health. 7 The Ministry of Health and DHBs with predominantly urban populations should identify Maori providers who can adapt the community model into a successful urban service to ensure that the goal of improving child oral health and reducing child oral health inequalities is achieved. 8 Maori providers should have capital equipment funding made available to them and repairs and maintenance components included in their contracts. Maori providers are not private practices and therefore more like the DHB provider arms than mainstream private practices. DHB contracts should be amended to reflect this as the lack f operational equipment means that oral health service can not be delivered. 9 Measures of performance are required to determine the effectiveness of the Maori child oral health services and to demonstrate how these services are improving Maori child oral health. A consistent framework that allows the components influenced by Maori providers should be used to accurately assess the effectiveness of these services. 10 Maori providers should be encouraged to develop their own oral health workforce through their relationships with training establishments and the development of further treatment services where Maori can gain important community experience and attraction to the oral health professions. 7 TP PT Mauri Ora Associates. (2004). Review of Maori Child Oral Health Services, New Zealand Ministry of Health Northland Oral Health Strategy, Feb 2007 Page 34 of 47 11 Te Ao Marama should be supported by the Ministry of Health and DHBs and be recognised as an important thread that brings together the Maori oral health workforce. 12 Further assessment of the wider oral health system should be undertaken to determine how organisational and systemic issues affecting Maori oral health providers can be improved. Northland Oral Health Strategy, Feb 2007 Page 35 of 47 Appendix 3 Recommendations from SDS review The SDS Review required the DHB to undertake a stock-take of current facilities and then make recommendations regarding an optimum service configuration for the future. In order to decide what type of service would best suit each school we developed a decision framework. The 3-stage process was as follows: 1 Assign a risk/need rating for each school based on DMFT or decile, depending on what information was available School Risk Rating New Entrant DMFT <2 2-4 >4 Unknown Low Med High Form 2 DMFT <2 2-4 >4 Unknown Low Med High School Decile 1-2 3-4 5 - 10 High Med Low 2 Weight the school roll to reflect the level of risk/need. The weighting is to reflect the fact that children with high levels of risk or need require more contact with the therapists. Roll weighting based on risk: • high risk = x2 • medium risk = x1.5 • low risk = x1 3 Recommend type of clinic based on the weighted roll size. Northland Oral Health Strategy, Feb 2007 Page 36 of 47 Assigning Clinic Type Weighted Roll < 90 90-500, and/or low risk > 500, and medium or high risk Mobile clinic Fixed Clinic Difficult Site Access Easy Site Access Single Mobile Double Mobile < 750 Case by case basis considering isolation, size, need and social demographics Options: • Own transport to nearby clinic • DHB transport • Mobile clinic visiting Renovate Existing Static need/ numbers Growing need/ numbers Single Fixed Clinic Double Fixed Clinic > 750 Building from Scratch Double Fixed Clinic The findings from the decision tree were then summarised into an optimum service configuration. Northland Oral Health Strategy, Feb 2007 Page 37 of 47 Double Fixed Clinic Below is a summary of the recommended optimum configuration for SDS, compared with the current configuration: Recommended Actual SDS roll (2003) 26,496 Weighted roll (based on need/risk) 40,953 Current Gap Therapist/assistant teams required (based on weighted 1100 children per team) 37 23.4 13.6 Fixed clinics 23 63 -40 Schools to receive mobile service 88 55 33 Double mobile units required 9.5 0.5 (could be 1) 8.5 Schools needing consideration (roll <90) 32 32 The resources that would be required to bring the current service up to the optimum are: Capital costs: One-off operating costs: Ongoing operational costs 14 sets of operational equipment 13.6 therapist/assistant teams upgrade IT patient management systems (mix of capital and operating) equipment replacement and maintenance replace 12 clinics refurbish 11 clinics 8.5 double mobile units truck to move mobile units replace 46 chairs 8.6 FTEs of oral health promoters maintenance and diesel etc for truck and trailers 27 xrays and processors other equipment (see estimates) If the SDS service structure was retained as is, the SDS review identified a total estimated cost of: • $8,803,100 to bridge the gap between the current service and the optimum configuration • an ongoing additional cost of $1,362,600 per year (excluding IT needs). Northland Oral Health Strategy, Feb 2007 Page 38 of 47 Appendix 4 Private Provider Survey Results Summary The questionnaire was sent to 16 contracted providers (covering 26 dentists) and 7 noncontracted providers (11 dentists). 9 contracted (56%) and 4 non-contracted (57%) questionnaires were returned. Of the 9 contracted providers who responded: 4 limit their adolescent numbers to children of existing patients. 3 intend to offer the service for less than 1 year; 2 for 1-3 years; and only 3 for more than 3 years (one didn’t answer). All except one said the service was uneconomic; 6 said it was bureaucratic; 5 didn’t like the clinical restrictions. 8 provided adult care under Work and Income contracts. The key areas identified for DHB support were improving the handover from SDS and promotion of the adolescent service. Most do not have an electronic patient management system, though most would be interested in contributing to a regional data collection. Of the 4 non-contracted providers who responded: 1 sent a blank questionnaire back. 1 was interested in entering into a contract and 1 was undecided. There were many reasons for not holding a contract. All said it was uneconomic, bureaucratic, and clinically restrictive. Other comments were about cultural correctness, racially biased documents, and the unreliability of children. All 3 provided services to low income adults under Work and Income contracts. 2 were interested in attending an evening to learn more about the OHSA contract. Contracted Providers Questionnaire 9 Responses Received Do you currently treat any adolescents (Form 3-18 th birthday) as completely private patients i.e. NOT under the adolescent oral health contracts? P P Yes. How many private adolescent patients would you treat regularly? 3 Exact Number if known: ______________________ Otherwise, estimated: 1 – 50 2 51 - 100 101 - 500 501 -1000 Over 1001 No/Not Sure 5 Northland Oral Health Strategy, Feb 2007 Not answered 1 Page 39 of 47 Do you accept Special Dental Benefit patients on referral from the School Dental Services? Yes 3 No 6 Please state the number of adolescent patients currently enrolled with your practice under your contract. Exact Number if known: ______________________ Otherwise, estimated: 0 – 50 1 51 – 100 2 101 – 500 2 501 – 1000 2 (based on actual claims there is only one provider in this category) More than 1000 Not Sure 2 Do you limit the number of Adolescents patients you have registered with your practice? No Yes, because 5 Adolescent enrolments are limited to children of existing patients 4 Patient numbers are at full capacity (books are full) 1 Adolescent numbers were getting too many to be financially viable to my practice 1 Other reasons, please state 1 The fees paid under the DB system are totally inadequate to cover the cost of treatment and have been for years. The practice has these patients at a loss! What is the ideal number of adolescents you would like to enrol and treat? Less than you currently have and to what number? _________________ The same as you currently have 5 More than you currently have and to what number? _________________ No ideal None 2 Not answered 1 How long do you intend to continue providing services under the adolescent contract? Less than 1 year 1 – 3 years 3 2 3 years and longer Not answered 1 3 If you were to consider resigning your contract it would be because of: Uneconomic for your practice 8 The bureaucracy associated with the contract and the payment systems Clinical restrictions 6 5 Other – please specify 1 The contracts are unrealistic and there should be more consultation personally with the contractors so we can have a mutually satisfying relationship and contract. Do you currently charge any patients under the adolescent contract for any of the following: Northland Oral Health Strategy, Feb 2007 Page 40 of 47 Repairs to accidentally damaged teeth that are eligible for ACC funding Non-Amalgam filling to posterior teeth (greater than one surface) Orthodontics 3 (if not fully covered) 5 7 Oral Surgery (for wisdom teeth removal) Root Canal Treatments No Other – please specify 2 Sedation, Antibiotics 1 Do you provide diagnostic screening/examination services or treatments for adolescents off site from your base surgery? No 8 Yes, Please list establishments where these services are provided and provide details of level of examination or treatment provided. 1 - Ruakaka Do you currently provide dental care for any adults (over 18 years) under Work and Income contracts? Yes, if so, approximately how many per year? ________________ 4=Y (no number), 1=20, 1=156, 2=200 No 1 Please outline below the type of DHB support you would see as most useful: An improvement in hand-over of Form 2 children from the school dental service? Promotion of the availability of the free adolescent oral care? 3 3 Assistance with follow up when patients do not keep appointments? 1 Other, please specify 4 Support in consistency in brief given to software company – constant updates A realistic contract with realistic fees Improve SDS, provide a better remunerated, less restrictive package for adolescents When a DHB dentist is in the area they should be the first referral base for SDB patients Not answered 2 Do you have a PMS (patient management system) in your practice? Yes 3, No 4, Not understood 1, Not answered 1 If so, what kind? Software of Excellence, Exact Dental, Not answered If not, are you considering getting a PMS system? Yes 1, No 2, Not understood 1, Not answered 1, would like further information 1 Would you be open to contributing information about patients treated under public contracts into a regional data collection? Yes 4, No 1, Not answered 3, Depends on cost and staff time 1 Northland Oral Health Strategy, Feb 2007 Page 41 of 47 Non-Contracted Providers Questionnaire 4 responses received – one with no answers so that is not included in the summary Do you at some stage in the future wish to hold a contract with a DHB for the provision of dental care to adolescents? Yes, I do wish to hold a contract Undecided 1 1 No, I do not wish to hold a contract 1 You do not hold a contract with a DHB for the provision of dental care to adolescents for the following reason(s): Uneconomic for my practice 3 The bureaucracy and paperwork associated with the payment systems 3 The new Oral Health Services Agreement (Contract) is too complex and difficult to decipher 2 Clinical Restrictions on materials and techniques I can use 3 Other, please specify 3 Cultural correctness is beyond what is needed to provide quality care Unreliability of children in this area Contract is a racially biased document, dealing with people you can’t trust Do you currently provide dental care for any adolescents (aged from 13 to 18) as private patients? Yes, if so, approximately how many? ___________________________ 6-12, 100-200, 200 No Do you currently provide dental care for any adults (over 18 years) under Work and Income contracts? Yes, if so, approximately how many per year? ____________________________ Yes, 11, 100 No Would you be interested in attending an information evening to learn more about the new Oral Health Services Agreement (Adolescent contract)? Yes 2 No 1 No-one from the Government of Health department have ever in my 30 years practising, kept their word. Northland Oral Health Strategy, Feb 2007 Page 42 of 47 Glossary Terms in italics have their own entry. Term ACC caries, dental caries chronic Combined Dental Agreement (CDA) completion Explanation Accident Compensation Corporation. The disease that causes decay to teeth and results in ‘holes’ which require filling. Used to describe an illness, disease or disability of long duration, and which has developed slowly. Chronic conditions are usually permanent or incurable, so that management to minimise discomfort and cost of services is important. (See also acute). A combination of OHSA and SDB. DC In oral health services, the stage at which all the needs identified during an intitial assessment have been met, which may take more than one visit. District council. decile See deprivation. dental therapist A health worker trained to provide care in primary and intermediate school settings, under the supervision of a dentist. Dental therapists work for DHBs and used to be called ‘dental nurses’. Describing those with high, often multiple, needs (often used loosely to mean ‘poor’, though income is only one of the factors considered). The most widely quoted source of data on deprivation is the NZ Deprivation (NZDep) scale which analyses 5-yearly Census data to describe deprived populations. Once ‘deprivation index’ scores are calculated across the whole of New Zealand, the data is divided into deciles, 10 population groups of equal number. (These deciles are calculated differently, and use a different scale to the school deciles used by the education system.) District Health Board. deprivation, deprived DHB diabetes District Annual Plan (DAP) DMFT epidemiology ethnicity A complex condition in which the body is unable to control the amount of glucose (sugar) in the blood, either because there is not enough of the hormone insulin or it does not work effectively. Uncontrolled diabetes can lead to metabolic disturbances that increase the risk of long term complications and affect a number of the body’s systems. 90% of diabetes is type 2, acquired as a consequence of unhealthy lifestyle, and is usually related to excess weight gain; onset is gradual. About 10% of diabetes is type 1, a result of the pancreas malfunctioning whose cause lies in viral infection and a breakdown in the body’s autoimmune systems (not lifestyle); onset is usually rapid and can be life-threatening (see ketoacidosis). Northland DHB’s statement of its intentions for the coming year. (See also District Strategic Plan.) Decayed, missing, filled teeth. The number of teeth in a mouth that have been damaged, lost or repaired. A population science concerned with the distribution and determinants of health- and disease-related states in human populations. A measure of cultural affiliation defined by Statistics New Zealand as a social group whose members share a common origin, claim a common Northland Oral Health Strategy, Feb 2007 Page 43 of 47 Term FTE GDB HealthPac Healthy Eating, Healthy Action (HEHA) Explanation sense of distinctive history and destiny, possess one or more dimensions of collective individuality and feel a sense of unique collective solidarity. Full-time equivalent General Dental Benefit, the subsidy formerly paid to private dentists to treat adolescents, overtaken now by OHSA.. Part of the Ministry of Health which processes all payments of public sector health funding, as well as being the central site for health sector contracts. A Ministry of Health-driven strategy which aims to identify, promote, and coordinate programmes for healthy nutrition and appropriate physical activity at national, regional, community and iwi levels. Hospitalisation inequality The process of attending hospital as a patient. It includes 3 main types: inpatient, a patient who stays at least one night in hospital outpatient, a person who is seen in a non-inpatient setting, or ‘clinic’, by a specialist after referral from a GP daypatient, a patient who undergoes an operation or other procedure in hospital and able to return home without staying overnight. The term ‘hospitalisation’ is often used loosely to mean one or any combination of the 3 types. See reducing inequalities. inpatient See hospitalisation. life-course, life-course continuum, life-course approach Another name for a model of disease progression developed by Leading for Outcomes. It maps the flow of chronic disease from early risk through to advanced symptoms, complications and death. One of the aims is to get health services to think about how they could work together better to keep people towards the ‘left-hand’ end of the continuum. A provider of health services which is run by Maori for Maori (as distinct from a ‘mainstream’ provider who deals with Maori clients or patients). A Maori co-funder organisation, Northland DHB’s funding and planning partner (the name persists from the days when they were called ‘ Ma ori p urchasing o rganisations’). NDHB deals with 2: Te Tai Tokerau MAPO (whose responsibilities for Maori correspond with the DHB’s responsibilities for the population bounded by the Whangarei and Far North territorial local authority areas) and Tihi Ora MAPO (whose responsibilities for Maori coincide with the DHB’s responsibilities for the Kaipara district). Relating to the jaws and face, particularly with reference to specialised surgery of this area. Ministry of Health. Maori provider MAPO U U maxillofacial MoH NDHB U U U U Northland District Health Board, which has 2 parts, NDHB Funder and NDHB Provider. The NDHB Funder is that part of NDHB that has been legislated to carry out the funding function for health services in Northland. The funder assesses needs, sets priorities for services, allocates funds, lets contracts to providers, and monitors performance. The NDHB Provider is that part of NDHB that provides health services (as distinct from the NDHB Funder). The majority of the Provider Service’s funding goes on Secondary care services. In the strategy Northland Oral Health Strategy, Feb 2007 Page 44 of 47 Term NOHPG Explanation documents, ‘NDHB’ refers to the whole organisation with involvement as relevant in each case from the funder or from the provider arm. Northland Intersectoral Forum, which comprises representatives from councils and government organisations throughout Northland. Northland Oral Health Planning Group NZDA New Zealand Dental Association. obese, overweight Degrees of excess weight, as defined by the Body Mass Index (BMI). Overweight = BMI 25-29 for Europeans, 26-31 for Maori and Pacific. Obese = BMI 30+ for Europeans, 32+ for Maori and Pacific. (Acceptable figures differ across ethnic groups because of variations in bodily composition and how this relates to risk of developing health problems such as heart disease and diabetes). Oral health. NIF OH OHSA orthodontics outcome patient management system PDO primary health care Primary Health Organisation (PHO) reducing inequalities risk factor Oral Health Services Agreement, the contract private dentists may choose to sign to provide free services to adolescents. See also Combined Dental Agreement (CDA). The use of devices to move teeth or adjust underlying bone. The result of an action. As distinct from an output, which is a measure of an activity rather than the result it has. An operation to mend a broken leg is an output, while the return to full function of the leg is the outcome. In a bigger picture sense, a focus on outcomes aims to analyse how effectively health services are provided and how well they work together. A system for managing data about all the people to whom an organisation provides services. Principal Dental Officer. Health services provided in the community which people can access themselves. The most well known are those provided by general practitioners, though they also include pharmacy services, private physiotherapists and, increasingly, nurse practitioners. (See also secondary services, tertiary services). A group of providers of primary health care services whose responsibility is to look after the people who enrol with them (those who are ‘on the register’). PHOs include GPs as well as a whole range of primary health care providers and practitioners (Maori and community health service providers, nurses, pharmacists, dietitians, community workers, and many others). As well as providing traditional primary health care services, PHOs must improve access to services for those with higher needs (such as Maori or those with chronic health conditions), have a focus on preventing ill health (rather than waiting till they are visited by sick people) and improve the way services work together. Inequalities in the health status of populations exist by socioeconomic status, ethnicity, gender, age and geographical areas. The reducing inequalities approach is about recognising these and proactively planning, funding and delivering services to reduce these differentials. A factor, which may be biological (such as a genetic predisposition) or associated with behaviour (such as smoking), that increases the likelihood of a disease developing. Northland Oral Health Strategy, Feb 2007 Page 45 of 47 Term SDB SDF SDS specialist Whanau Ora Explanation Special Dental Benefit. When dental therapists in the School Dental Service are unable to treat children aged 0-12 (either because their oral health needs are outside their scope of practice or they have special needs arising from, for example, a disability) they are referred to a dentist (either public or private) for treatment. Funding paid under the SDB enables dentists to provide this service. See also Combined Dental Agreement (CDA) Service Development and Funding, the planning and funding team within the NDHB Funder. School Dental Service, part of Northland DHB. A physician or surgeon, usually based in a hospital, who has undertaken extra training on top of the normal medical degree to specialise in a particular type of service or disease. Also called a consultant. A Ministry of Health-driven process aimed at supporting healthy Maori families which emanates from He Korowai Oranga. It aims to identify and extend whanau strengths and build them into initiatives throughout the health sector. Northland Oral Health Strategy, Feb 2007 Page 46 of 47 References 1 Good Oral Health for All, for Life: A New Strategic Vision for Oral Health in New Zealand. Ministry Of Health, Wellington, Aug 2006. 2 New Zealand Health Strategy. Ministry Of Health, Wellington, Dec 2000. 3 Maori Health Strategy. Ministry of Health, Wellington, Nov 2002. 4 Child Health Strategy. Ministry of Health, Wellington, June 1998. 5 DHB Toolkit: Improve Oral Health. Ministry of Health, Wellington, Jan 2004. 6 Achieving Health for All People: A Framework for Public Health Action for the New Zealand Health Strategy. Ministry of Health, Wellington, Oct 2003. 7 Primary Health Care Strategy. Ministry of Health, Wellington, Feb 2001. 8 Improving Child Oral Health and Reducing Child Health Inequalities. Public Health Advisory Committee, May 2003. 9 NDHB Strategic Asset Management Plan, Child and Adolescent Oral Health. NDHB, June 2005. 10 NDHB Child and Adolescent Oral Health Service Plan for Northland. NDHB, June 2005. 11 Maori Child Oral Health Service Review. Ministry Of Health, Wellington, 2004. 12 NDHB School Dental Services Review Report. NDHB, June 2004. 13 Health is Everybody’s Business: Working together for Health and Wellbeing. Public Health Advisory Committee, June 2006. Northland Oral Health Strategy, Feb 2007 Page 47 of 47