Download Central Lancashire Primary Care Trust Oral Health Strategy and

Oral Health Strategy
2007
Contents
Acknowledgements
iii
Executive summary and recommendations
iv
1. Introduction
1
2. Central Lancashire PCT Oral Health Priorities
2
3. The Oral Health and Needs of Central Lancashire Residents
5
3.1 The population of Central Lancashire
5
3.2 Oral health of children
10
3.3 Oral health of adults
17
3.4 Access to primary dental care services
19
3.5 Access to dental services for vulnerable patients
21
3.6 Prison dentistry
23
3.7 Central Lancashire Dental Workforce Development
24
3.8 Standards
25
3.9 Access to NHS secondary and tertiary dental care services
26
3.10 Access to NHS unscheduled dental care services
28
Appendices
29
Key reference list
39
ii
Acknowledgements
This strategy builds on the Oral Health Strategies created for the Chorley and South
Ribble, Preston and Central Lancashire Primary Care Trusts. It has been developed
through the Central Lancashire Primary Care Trust Oral Health Strategy and
Commissioning Group. Large numbers of people have contributed to and facilitated
this work. Some are no longer associated with the Primary Care Trust’s oral health
and dental agenda. We would like to extend our thanks to them all.
Eric Rooney
Consultant in Dental Public Health
Melanie Catleugh
Consultant in Dental Public Health
Central Lancashire PCT
2007
iii
Executive summary

This paper describes the oral health needs of the population of Central
Lancashire Primary Care Trust (PCT). It aims to make specific
recommendations that are intended to inform all commissioning decisions
made by the PCT that concern the prevention of oral disease and provision of
dental services.

This PCT aims to:



Improve the health of the community
Secure the provision of high quality services that meet the needs of
the local population
Integrate health and social care locally by ensuring it works with all
partners, including local people, effectively.

The following recently published guidance and legislation can assist the PCT
in addressing the these strategic aims as they relate to oral health and
dentistry:
o Choosing Better Oral Health
o The Health and Social Care (Community Health and Standards) Act
2003
o NHS Dentistry: Delivering Change
o 2005 amendment to the 1999 Health Act
o Our Health, our care our say: a new direction for community service

Central Lancashire is home to approximately 450,000 people, and is
concentrated in, Chorley, Leyland, Preston, Ormskirk, and Skelmersdale.

Some Central Lancashire residents are amongst the most deprived in the
country. The majority of these residents live in the Preston and Skelmersdale
areas.

The highest proportion of Black and Minority Ethnic (BME) residents of
Central Lancashire live in Preston. The largest BME community in Central
Lancashire being Asian.

Children from Asian families have significantly poorer dental health than their
white peers

Central Lancashire has three Prisons within its locality, these being, HMP
Garth, HMP Preston and HMP Wymott.

Some of the residents of Central Lancashire have, on average, lower life
expectancy and higher levels of ill health compared to others within the PCT
locality, and with national averages. This can affect oral health.
iv

There are a number of Central Lancashire residents from vulnerable groups
who require special consideration when the PCT is commissioning oral health
advice and dental services. These include people with a long-term limiting
illness, looked after children, homeless people, those with HIV/ Aids and
substance abusers.

In general terms the level and severity of dental caries in children living in
Central Lancashire is, and has remained, persistently high since the mid
1990s, compared with national averages.

There are marked inequalities in children’s oral health within the PCT. One in
two five year old children attending school in the former Preston PCT area
had experience of dental caries in 2005/2006. The average level of caries
severity in Preston is also greater than the average for the North West.
Caries is less severe in the former Chorley and South Ribble and West
Lancashire PCT areas.

The consequences of suffering from dental caries for children include severe
pain, abscess formation, sleep loss for patients and parents or carers and
behavioural problems. Further, suffering from caries in childhood is the
strongest predictor for suffering from caries later in life.

There is a need and marked demand for all orthodontic treatment in Central
Lancashire. However, new regulations mean that only the most severe cases
can be treated under NHS arrangements. The impact of this new regulation
on the need and demand for orthodontic treatment is yet to be assessed.

National data, collected during the Child Dental Health Survey in 2003,
revealed that, although the prevalence is falling, five percent of eight year
olds and 13% of 15 year olds had signs of dental injury.

More adults in Central Lancashire are expected to have natural teeth
compared with the 1970s.

Adults in the North West have higher levels of oral disease than others in
England. This, added to high levels of disease in children, impacts on the
need for services.

A small number of people in Central Lancashire have lost their lives because
they suffered from oral cancer. Early diagnosis of oral cancer improves the
chances of survival. Risk factors include tobacco use and alcohol
consumption.

Currently Central Lancashire PCT commission 750,000 Units of Dental
Activity from practitioners working in primary dental care. The majority of
these practitioners work in one of 55 practices in Central Lancashire.

A conservative estimate suggests that there are in excess of 12,000 patients
waiting to be allocated to local dentists for routine care. The majority of these
live in Preston and Chorley and South Ribble.
v

A developing Salaried Primary Dental Care Service currently operates across
Central Lancashire. Nine clinics provide access appointments for those
patients requiring urgent care and routine appointments for referred patients.
In addition, special care dentistry, specialist paediatric dentistry and dental
services for phobic patients are provided.

Central Lancashire residents requiring extractions, or in special cases dental
treatment under general anaesthesia, are treated at either Chorley & South
Ribble District General Hospital, The Royal Preston Hospital or Ormskirk &
District General Hospital through the Salaried Primary Dental Care Services.
There is currently a lengthy waiting list for these services at Ormskirk &
District General Hospital.

A survey of prisons in Cumbria and Lancashire is currently being undertaken
to identify key oral health and dental service challenges to inform future
development. Some priority areas have been identified.

A survey of the dental workforce in Cumbria and Lancashire was carried out
in August 2004. This identified issues relating to workforce composition and
dental nurse registration.

The new Cumbria and Lancashire Dental School based at the University of
Central Lancashire, Preston, will provide dental undergraduate education
from September 2007. Cumbria and Lancashire provides approximately 45
vocational training places, and trains 18 dental therapists per year. A number
of these trainees have been placed in the Central Lancashire PCT locality.
An increase in training placements to support a range of training will be
required in the future.

Central Lancashire PCT engages the services of two General Dental Practice
Advisers who assess primary dental service providers’ performance against
health standards. Both advisers have a programme of dental practice
inspections. Environmental assessments are also carried out by the NHS
Business Services Authority Dental Division.

Oral and maxillofacial surgical services are provided for residents of Central
Lancashire by Lancashire Teaching Hospitals NHS Foundation Trust in
Preston and Chorley. A small amount of advanced restorative treatment is
also provided by Lancashire Teaching Hospitals NHS Trust.

The former Preston PCT developed a single point of access for all
unscheduled dental care. Initial emergency dental treatment is provided from
Saul Street Clinic in Preston and access sessions are commissioned within
independent dental contractors. Patients seeking routine care are placed on
an access database and subsequently transferred to routine care.

Chorley South Ribble and West Lancashire localities currently do not have a
single point of access to dental services.

An Emergency Dental Service operates each week day evening, weekends
and Bank Holidays.
vi
The following recommendations are made:
1. Data relating to the dental needs of all groups at increased risk of developing
oral disease, or for whom dental diseases are challenging to treat, should be
collected.
2. Access to tailored oral health advice and dental services should be available
to address the specific needs of all patients from vulnerable groups and those
incarcerated in prisons in the locality.
3. All preventive dental interventions currently commissioned by the PCT should
be evaluated. Only those, which are effective, should be commissioned in the
future.
4. The PCT should seek to reduce overall levels of caries by supporting the
introduction of water fluoridation in Central Lancashire.
5. The PCT should aim to reduce oral health inequalities by increasing
evidence-based targeted prevention activity in the under fives.
6. The PCT should ensure that commissioned dental services can demonstrate
improvements in the quantity and quality of evidence-based preventive
practice.
7. The PCT should engage with other health and non-health agencies to reduce
the quantity and frequency of sugar individual sugar consumed by
individuals, and the frequency of at which it is consumed.
8. The PCT should measure the impact of the funding constraints of NHS
orthodontic treatment and reassess needs and demands for orthodontic
treatment.
9. No investment in orthodontic services is recommended at this time.
10. The PCT should implement at least one intervention working in partnership
with health and non-health agencies to reduce the incidence of dental
injuries.
11. The PCT should ensure that commissioned primary care dental services play
a part in the delivery of its tobacco control agenda.
12. To ensure that a comprehensive periodontal examination is carried out for
each patient attending practices and clinics.
13. The PCT should seek to engage with other health professionals to ensure
timely referral of patients to secondary care when they are suspected to be
suffering from oral cancer.
14. Performers should ensure that a comprehensive soft tissue examination is
carried out for each patient attending primary dental care services.
vii
15. The PCT should ensure that commissioned services promote abstinence
from tobacco use, and sensible alcohol consumption.
16. The PCT should increase commissioning of dental services where there
appears to be inequitable access in high treatment need areas.
17. The PCT should also commission services where there is comparatively
more demand.
18. The PCT should continue to develop the Salaried Primary Dental Care
Services, in collaboration with the Clinical Directors.
19. The PCT should identify the cause of the long waiting list at Ormskirk &
District General Hospital.
20. The PCT should commission, if appropriate, a waiting list initiative to reduce
the existing length of wait for dental treatment under general anaesthesia at
Ormskirk & District General Hospital.
21. If the cause of the long waiting list cannot be remedied, the PCT should
consider commissioning dental services from another provider.
In
accordance with national guidelines the waiting time for patients from referral
to treatment should be no longer than 18 weeks.
22. Oral care should be incorporated into all health plans for vulnerable groups
where possible.
23. All commissioning decisions with regards to special care dentistry should be
informed by the British Society of Disability and Oral Health Commissioning
Tool.
24. Following the review currently being undertaken, prison dental services
should be aligned across all three prisons to ensure equity.
25. The PCT should support a modernisation agenda of dental services across
all three prisons.
26. The PCT should commission an update of the Dental Workforce Survey for
Central Lancashire.
27. A workforce plan should be developed to ensure future recruitment and
commissioning is linked to service development.
28. As part of the work force plan the PCT should support the development of
training practices/services in Central Lancashire to meet the training needs of
the future dental workforce.
29. The PCT must work with the General Dental Practice Advisers to develop a
consistent approach to quality assessment and control across all providers of
primary care dental services.
viii
30. The PCT should commission a review of secondary care services provided in
its locality, which relate to oral surgery, orthodontics and other dental
specialties.
31. The PCT should re-commission all care currently being undertaken in a
secondary care setting, which could be carried out in a primary care setting.
32. The PCT should align all unscheduled dental care services to utilise current
expertise and provide a seamless service.
33. A single point of contact should be developed to provide consistency for
service users within the PCT.
34. The PCT should commission in and out of hours unscheduled care based on
locality demand.
35. A review of the current, potential, and the setting of unscheduled service
provision should be undertaken.
ix
1. Introduction
This paper describes the oral health needs of the population of Central Lancashire
Primary Care Trust (PCT). It aims to make specific recommendations, which will
improve the oral health of the local population and reduce oral health inequalities. It
is intended to inform all commissioning decisions made by the PCT that concern the
prevention of oral disease and provision of dental services over the next five years.
The paper is divided into three sections. The first section outlines the PCT’s
priorities and, by drawing on some key national guidance and legislation, identifies
broad aims relating to improving oral health and dental services. The second
provides a description of the population of the PCT of relevance to oral health and
dental services, outlines what is known about the oral health status of its residents,
and describes access to NHS dental services in the locality. Throughout this section
specific recommendations are made relating to aspects of oral health and dental
service needs of the Central Lancashire population.
Central Lancashire PCT recognizes the importance of both clinical and public
engagement. This document will therefore be subject to both public and
professional scrutiny through a formal consultation. Following this, a revised
document will be released by the PCT. This strategy will be revised in 2012.
Progress made against the aims and objectives listed in the final section will be
regularly monitored.
1
2. Central Lancashire PCT Oral Health Priorities
Central Lancashire PCT (PCT) is a new organisation, which has existed since
October 2006, and is made up of the former Chorley and South Ribble, Preston and
West Lancashire PCTs. A Local Delivery Plan is currently being developed. This
PCT aims to:
 Improve the health of the community
 Secure the provision of high quality services that meet the needs of
the local population
 Integrate health and social care locally by ensuring it works with all
partners, including local people, effectively.(1)
There are a number of guidance documents that have been released nationally
which can assist the PCT in addressing these strategic aims as they relate to oral
health and dentistry. This section makes reference to these guidance documents
and outlines priorities, which the PCT must recognise as being important for its
population.
Improving oral health through evidence based preventive interventions and
partnership working.
Choosing Better Oral Health was published in November 2005.(2) It is an action
plan, linked to the wider public health strategy Choosing Health, which is designed
to assist and support PCTs and the local dental profession in addressing oral health
and dental service issues. It highlights six key areas that it considers important to
gain sustainable improvements in oral health. These are listed below:
 The increased use of fluorides.
 The improvement of diet and reducing sugar intake.
 The encouragement of evidence-based preventive dental care.
 Contributing to reductions in smoking prevalence and tobacco
related harm.
 Increasing the early detection of mouth cancer.
 Reducing dental injuries.(2)
The PCT should identify these as priority areas for action. It must recognise that
achieving real change in each area must be heavily reliant on the sole use of
evidence-based interventions. It should also acknowledge that effective partnership
working between dental teams, health and non-health agencies is essential in
addressing these areas.
2
Securing the provision of high quality dental services to meet the needs of the
Central Lancashire population.
The Health and Social Care (Community Health and Standards) Act 2003 gave
PCTs the responsibility for the provision of primary dental care services to meet the
needs of the populations they serve, to the extent that they consider necessary.
They are responsible for commissioning both general dental care and more
specialist dental care.(3) Policies detailing methods of removing barriers for disabled
people must be provided in accordance with the Disability Discrimination Act 1995.
NHS Dentistry: Delivering Change, published in 2004, set out the Government’s
plans for the reform of NHS dentistry in England. Its stated vision was to build an
NHS Dental Service that offers access to high quality treatment for patients when
they need to see a dentist; focuses on preventing disease; and gives a fair deal to
dentists and their teams. (4)
An amendment to the Health Act, approved in 2005, meant that from July 2006
dental care professionals including dental nurses, technicians, hygienists and
therapists, would be required to register with The General Dental Council (the dental
profession’s regulatory body). This will serve to formalise the career structure of
members of the dental team. It is now even more important for the PCT to enhance
the working lives of these important members of the dental team and offer support in
professional training.
The Government white paper, Our Health, our care our say: a new direction for
community service was published in January 2006. It emphasised the need for more
prevention and for PCTs to offer a greater choice or services which are more
personalised.(5) Recommendations from this document led to the development of
the The Care Closer to Home Demonstration Project. This was set up to evaluate
new models of care. In addition, the Department of Health has published a
commissioning framework, Commissioning for Health and Wellbeing.(6) This places
a focus on a patient-centred partnership approach to commissioning services.
Considering the above legislation and guidance it is recommended that the PCT:





Continues to improve access to appropriate dental services to meet the
needs and preferences of all patients in the locality.
Achieve and maintain high quality treatment provision.
Improve the working lives of members of the dental team.
Support professional training.
Enhance patients’ choice of dental and oral health services.
3
Other Priorities
Additional priorities for the PCT must include the collection of essential data, which
will inform needs assessment and commissioning decisions. This should include
engagement in local, policy relevant, research relating to oral health and dental
services.
4
3. The Oral Health Needs of Central Lancashire Residents
3.1 The population of Central Lancashire
This section outlines the features of the population of Central Lancashire, and
groups within it, that are likely to affect the need for particular types of preventive
interventions to be implemented and for dental services to be commissioned.
Resident population
Central Lancashire is home to approximately 450,000 people. Within Central
Lancashire there are four Local Authorities these being Preston City Council
(Preston), South Ribble Borough Council (South Ribble), Chorley Borough Council
(Chorley) and West Lancashire District Council (West Lancashire). The highest
concentration of population within Central Lancashire is in Preston (9.2%) and the
lowest is in Chorley (7.1%).(7) This is illustrated in Figure 1.
Fig 1
Preston
Preston
Leyland
Leyland
Chorley
Chorley
Population Density
by LSOA
More Dense
Ormskirk
Ormskirk
Skelmersdale
Skelmersdale
Less Dense
5
When comparing the age structures of the resident populations of the four Local
Authority areas within Central Lancashire. Preston has the highest number of older
residents. However there is a notably larger proportion of the population in West
Lancashire who are aged between 50 and 85 years.
There are marked socioeconomic differences within Central Lancashire and when
Central Lancashire as a whole is compared with other PCT localities in the country.
Figure 2 illustrates the socioeconomic differences within Central Lancashire. A
more detailed map can be found in Appendix One. All Local Authorities within
Central Lancashire have areas that are within the most deprived in the country. The
main areas of deprivation are in Central Preston and Skelmersdale.(7)
Evidence exists of a strong link between deprivation and dental caries levels in
children.(8) Studies have consistently shown that the most disadvantaged children
are likely to have the highest levels of caries and consequently worse oral health.
(9)
Fig 2: Areas of deprivation in Central Lancashire
Indices of Deprivation
In the 10% most deprived SOAs nationally
In the 20% most deprived SOAs nationally
In the 40% most deprived SOAs nationally
All other SOAs
6
Black and Minority Ethnic (BME) communities, which include individuals of mixed
ethnicity, make up approximately 5.5% of the total population of Central Lancashire,
compared to approximately 9% of the total population of England and Wales
(Census 2001). The largest of the BME communities in Central Lancashire is of
Asian origin. Out of the four authorities in Central Lancashire, Preston has the
highest percentage of BME residents and West Lancashire has the lowest
percentage. The BME population in the authority of Preston is higher than the
Lancashire average BME population.(7)
Evidence which demonstrates that children from Asian families have significantly
poorer dental health than their white peers has recently emerged. This effect is over
and above that of deprivation.(10) The majority of Central Lancashire’s BME
populations reside in the inner city areas where there are generally higher levels of
social disadvantage. This can worsen health inequalities in these communities, as
can issues about different access to health services.
Prison Population
Central Lancashire has three Prisons within its locality, these being HMP Preston,
HMP Garth and HMP Wymott. HMP Preston is a category B prison and local
remand centre and has a population of 690 (November 2006). a HMP Garth is also
a category B prison with a population of 650 (November 2006), there are plans to
increase this population by 180 from April 2007. HMP Wymott is a category C prison
with a population of 1050 (November 2006) a proportion of which are vulnerable
prisoners.b As a result of national population pressures and changes in the National
Offender Management System in general terms prison populations are expected to
increase.
General Health
Some of the residents of Central Lancashire have, on average lower life
expectancy, and higher levels of ill health compared to others within the PCT
locality, and with national averages.(7) For these residents poor general health can
have two effects on oral health. Firstly, some conditions, including those, which
involve loss of dexterity, can increase the risk of oral disease. Secondly dental
treatment for residents with poor health can be time consuming, physically difficult
and can involve risks. There are some population groups, which need particular
consideration when the PCT is commissioning dental services and oral health
promotion interventions. Notwithstanding the variable amount of local level data
relating to such groups, these are outlined below.
a Category B: prisoners who do not need the highest conditions of security but for whom escape must be
made very difficult.
b Category C: prisoners who cannot be trusted in open conditions but who do not have the ability or
resources to make a determined escape attempt.
7
Limiting long-term illness
The 2001 census data revealed that, in Central Lancashire, there were 83,744
people with a limiting long-term illness. Almost half of these were of working age.
West Lancashire and Preston have the highest proportions of their populations with
limiting long-term illnesses. It is possible that this group may have particular difficulty
in accessing appropriate dental care. (11)
More recently gathered data show that there are more than 1,100 people of working
age with physical disabilities helped to live at home in Central Lancashire.(12) There
are almost 1,000 adults in this age group with learning disabilities helped to live at
home.(13) At the end of September 2006 there were more than 4,800 older
residents of Central Lancashire helped to live at home.(14) Each year approximately
700 supported residents over 65 years of age are admitted to residential or nursing
care.(15) It is possible that residents in these groups may have particular difficulty in
accessing appropriate dental care and may need domiciliary care.
Other important population groups
Looked after children
At any one time there are approximately 350 looked after children in Central
Lancashire; the largest number live in Preston. In 2004, of those children who had
been continuously looked after for 12 months, in Preston almost one third had not
had their teeth checked. This was the case in West Lancashire, which has the
second highest number of looked after children. As looked after children are often
relocated, sometimes at short notice, they pose a particular challenge for healthcare
provision. It is essential that they receive preventive interventions where
possible.(16)
Homelessness
In total 872 households were accepted as homeless in the year 2003/2004. In this
year South Ribble and Preston had the highest levels of homelessness. These are
amongst the highest levels of homelessness in Lancashire. These groups also have
particular needs relating to service provision and prevention, because of their
potentially changing circumstances.(17)
HIV /AIDS
Mid year estimates for 2006 suggest that approximately 140 residents of Central
Lancashire are currently suffering from HIV/AIDS. There were eight new cases in
2005/2006.(18) There are a number of oral conditions linked to HIV/AIDS, which
have better outcomes if they are treated early.
8
Substance abuse
In relation to both legal and illegal drug (e.g. heroin, cocaine and cannabis) use,
about 28,000 people a year in the North West use Drug Treatment Services. This
represents a rate of four per 1,000 people. In Preston approximately 800 patients
access drug treatment services at any one time.
Recommendations:
1. Data relating to the dental needs of all groups at increased risk of developing
oral disease, or for whom dental diseases are challenging to treat should be
collected.
2. Access to tailored oral health advice and dental services should be available
to address the specific needs of all patients from these vulnerable groups and
those incarcerated in prisons in the locality.
9
3.2 Oral health of children
Dental Caries
Dental caries is a common, preventable condition, which involves the localised
destruction of tooth tissue. It is caused by a number of factors which relate to
interactions between teeth, microorganisms and dietary carbohydrates.(19) Fluoride
is an effective caries preventive measure.(20) Since 1985, local surveys, carried out
to nationally agreed criteria, have been conducted in the former Chorley and South
Ribble, Preston and West Lancashire PCTs. These provide statistics relating to the
prevalence and severity of dental caries, and are used to make comparisons within
and between regions in England. Currently, five-year-old children are surveyed
every two years. Surveys of the oral health of five-year-old children in Longridge
have been conducted as part of the former Preston PCT surveys. It has not been
possible to separate these data.
National targets for levels of dental decay in children have been set by the
Department of Health. These are shown in Figure 3.
Fig 3



Department of Health national caries targets 2003 for England
5 year olds should have no more than an average of 1.0 tooth with
decay (caries) experience
70% 5 year olds should have no decay (caries) experience
12 year olds should have no more than an average of 1.0 teeth with
decay caries) experience
National Statistics 2004
In general terms the level and severity of dental caries in children living in Central
Lancashire is, and has remained, persistently high since the mid 1990s. (Figure 4)
Graphs demonstrating this can be found in Appendix Two. The most recent dental
survey of children in Central Lancashire has revealed that more than one in two five
year old children attending school in the former Preston PCT area had experience of
dental caries. This level of caries exceeds the national target from 2003 and is
greater than that for the North West of England. Levels of caries prevalence in the
former West Lancashire and Chorley and South Ribble PCT areas are above the
national target but below the average for the North West. This is illustrated in Figure
5.
10
Fig 4
Central Lancashire 5-year-old caries prevalence
80
Chorley
75
South Ribble
Preston
West Lancashire
North West
England
Target
70
65
60
Percentage
55
50
45
40
35
30
25
20
15
10
5
0
1995/96
1997/98
1999/2000
2001/02
2003/04
2005/06
The Dental Observatory
Fig 5
Central Lancashire 5-year-old caries prevalence
70
Central Lancashire
North West
England
65
60
55
Percentage
50
45
40
35
30
25
20
15
10
5
0
1991/92
1993/94
1995/96
1997/98
1999/2000
2001/02
2003/04
2005/06
The Dental Observatory
11
The graph shown in Figures 6 compares dental caries severity data collected from
five-year-old children since 1997, attending school in the three former PCTs, which
make up Central Lancashire.
Fig 6
Central Lancashire 5-year-old caries severity
3.75
3.50
Chorley
South Ribble
Preston
West Lancashire
North West
England
Target
3.25
3.00
Average dmft
2.75
2.50
2.25
2.00
1.75
1.50
1.25
1.00
0.75
0.50
0.25
0.00
1995/96
1997/98
1999/2000
2001/02
2003/04
2005/06
The Dental Observatory
Source: The Dental Observatory
The severity of dental caries experienced by children in the Central Lancashire PCT
far exceeds the national target. Currently, the average level of caries severity in
Preston is also greater than the average for the North West. Caries is less severe in
the former Chorley and South Ribble and West Lancashire PCT areas.
Notwithstanding these findings, marked inequalities exist within these former PCTs.
This is illustrated on Maps 3 and 4 in Appendix Two. These display census level
dental epidemiology data collected in the three former PCTs between 2001 and
2006.
The consequences of suffering from dental caries for children include severe pain,
abscess formation, sleep loss for patients and parents or carers, behavioural
problems and the need for extractions under general anaesthesia with its
associated, potentially life-threatening risks. Further, suffering from caries in
childhood is the strongest predictor for suffering from caries later in life. The impact
of this effect in older children in Central Lancashire has been measured by
assessing the prevalence and severity of dental caries in 12 year olds. This has
been carried out in the locality every four years. Twelve-year-old children have
permanent teeth, which are not replaced. This disease therefore has life-long
consequences. The most recent survey carried out in Central Lancashire revealed
12
that on average more than one in two 12 year olds had experience of dental caries
in Preston and West Lancashire, and one in two in Chorley and South Ribble.
This disease is however comparatively less severe than in five year olds, as the
average number of decayed missing and filled teeth is 1.46 in West Lancashire,
1.34 in Preston and 1.29 in Chorley and South Ribble. Nevertheless, this level is
higher than the average for England (0.86) and the national target (1.00)
Recommendations:
3. All preventive dental interventions currently commissioned by the PCT should
be evaluated. Only those, which are effective, should be commissioned in the
future.
4. The PCT should seek to reduce overall levels of caries by supporting the
introduction of water fluoridation in Central Lancashire.
5. The PCT should aim to reduce oral health inequalities by increasing
evidence-based targeted prevention activity in the under fives.
6. The PCT should ensure that commissioned dental services can demonstrate
improvements in the quantity and quality of evidence-based preventive
practice.
7. The PCT should engage with other health and non-health agencies to reduce
the overall quantity of sugar consumed by individuals, and the frequency of at
which it is consumed.
13
Orthodontic conditions
Since the mid 1990s data relating to orthodontic conditions and treatment need
have been collected through local surveys. Estimates of the needc and demandd for
orthodontic treatment have been calculated from the most recent survey in which
orthodontic data were collected. The estimated total need for orthodontic treatment
of the 12-year-old population of Central Lancashire was 1811of 12 year olds. The
demand for this group was estimated 1828 of 12 year olds. Proportional variations
between need and demand exist in the different districts within Central Lancashire;
this is presented in Table 1.
Table 1 – Children age 12 in Central Lancashire needing and demanding
orthodontic
treatment
% Demand
Estimate
Estimated
for
need
demand
orthodontic
(number)
(number)
treatment
District
Total 12
year old
population
% Need for
orthodontic
treatment
Chorley &
South Ribble
2,822
26.2
738
31.1
877
Preston
1,507
41.8
630
31.6
476
1,357
32.6
443
35.1
476
West
Lancashire
Central
Lancashire
5,686
1,811
1,829
Source: The Dental Observatory
Table 2 illustrates the most recent data relating to orthodontic need, collected from
teenagers aged 14 years. At this age, if orthodontic treatment is needed it would
routinely have been started. It is estimated that in the region of 1,300 teenagers, at
age 14 years, in Central Lancashire require orthodontic treatment and are not being
treated.
c Orthodontic need is defined as, children not wearing an appliance, who have been deemed to be in
need of treatment, as defined by the modified IOTN used nationally in the British Association for the Study of
Community Dentistry co-ordinated surveys.
d Orthodontic demand is defined as those children not wearing an appliance who would like orthodontic
treatment and would agree to receive orthodontic treatment
14
Table 2 - Children age 14 in Central Lancashire needing and demanding orthodontic
treatment
District
Total 14
year old
population
% Need for
orthodontic
treatment
% Demand
Estimate
Estimated
for
need
demand
orthodontic
(number)
(number)
treatment
Chorley &
South Ribble
2,858
23.9
684
21.0
600
Preston
1,712
25.3
432
21.8
373
1,346
18.9
254
17.5
236
West
Lancashire
Central
Lancashire
5,916
1,370
1,209
Source: The Dental Observatory
Since these data were collected the Department of Health has agreed to fund
treatment for only the most severe orthodontic needs. Orthodontic need is
traditionally assessed by using the Index of Orthodontic Treatment Need (IOTN).
This scale has two components and is scored from 1 to 5. To be eligible for NHS
treatment, a patient must have an orthodontic condition that scores more than 3.6
on this scale. This will certainly reduce normative need for orthodontic treatment.
The impact of this decision on demand for orthodontic treatment is not currently
known.
Recommendations:
8. The PCT should measure the impact of the funding constraints of NHS
orthodontic treatment and reassess needs and demands for orthodontic
treatment.
9. No investment in orthodontic services is recommended at this time.
15
Dental injuries
No local data relating to dental injuries are available. National data, collected during
the Child Dental Health Survey in 2003, revealed that, although the prevalence is
falling, five percent of eight year olds and 13% of 15 year olds had signs of dental
injury. Boys were more likely to sustain dental injuries than girls.
Recommendations:
10. The PCT should implement at least one intervention working in
partnership with health and non-health agencies to reduce the
incidence of dental injuries.
16
3.3 Oral health of adults
Dental Caries and Periodontal (Gum) Disease
Although there are no local adult dental caries prevalence data available for Central
Lancashire PCT, national data collected in the most recent UK Adult Dental Health
Survey in 1998 suggest that there is likely to have been a decrease in the levels of
caries in adults since the 1970s. A marked increase in the proportion of adults with
natural teeth compared with previous surveys was also clearly demonstrated.
Notwithstanding the general reduction in caries across the country, marked regional
differences were noted. For example, along with Northern and Yorkshire Regions,
dentate adults in the North West had the highest level of dental caries in the
country. Only 36% of adults in the North West, who had teeth, had none that were
decayed or unsound. This compares poorly with the South West where 59% adults
with teeth, had no teeth that were decayed or unsound. These findings, along with
the current levels of dental caries in the 12 year old population in Central
Lancashire, indicate that there will be a higher than average need for restorative
dentistry in Central Lancashire for adults in the future.
Similarly, no local data are available relating to the prevalence of adult periodontal
(gum) disease in Central Lancashire. The Adult Dental Health Survey carried out in
1998 found 54% of the adult population had some degree of periodontal disease.
Four percent had advanced periodontal disease. Thus, it is estimated that 190,000
adults aged 18 and over living in the Central Lancashire PCT area will have some
degree of periodontal disease, and in 14,000 this disease will be severe. There is a
considerable amount of evidence that smoking increases the risk of periodontal
disease and reduces the effectiveness of treatment. (21)
Recommendations:
11. The PCT should ensure that commissioned primary care dental services
play a part in the delivery of its tobacco control agenda.
12. To ensure that a comprehensive periodontal examination is carried out for
each patient attending practices and clinics.
17
Oral cancer
There is a dearth of local data on the incidence of malignant tumours of the lip, oral
cavity or pharynx. Between 2003 and 2005 six Central Lancashire residents lost
their lives due to oral cancer.
The main risk factors for oral cancer are tobacco use and alcohol consumption. The
chances of a patient surviving following a diagnosis of oral cancer are much greater
if it is detected early. (22)
Recommendations:
13. The PCT should seek to engage with other health professionals to ensure
timely referral of patients to secondary care when they are suspected to be
suffering from oral cancer.
14. Performers should ensure that a comprehensive soft tissue examination is
carried out for each patient attending the primary dental care services.
15. The PCT should ensure that commissioned services promote abstinence
from tobacco use, and sensible alcohol consumption.
18
3.4 Access to NHS Primary Dental Care Services
Most people access NHS primary care dental services in Central Lancashire
through their local dental practice. There are two legal frameworks under which
dental practice may be delivered. These are General Dental Services (GDS) and
Personal Dental Services (PDS). In contractual terms there is little difference
between the two. From April 2006 new contracts have been introduced that are
designed to sever the link between items of service and payment. For an agreed
contract value, dentists are expected to deliver an agreed number of units of activity
(UDAs), which relate to courses of treatment weighted by their complexity. Dentists
who worked under NHS regulations prior to April 2006 had a right to a guaranteed
contract and a minimum income guarantee. The minimum income guarantee ends
in March 2009 and this gives the PCT an opportunity to support innovation in
service delivery, and commission services in other ways which provide added value.
Currently Central Lancashire commissions slightly over 750,000 UDAs from local
dentists through GDS contracts or PDS agreements. Table 3 demonstrates the
proportion of this aggregated activity commissioned in each former PCT. Map 5 in
Appendix One illustrates the levels of dental activity in each NHS dental practice in
Central Lancashire.
Table 3: Number of Units of Dental Activity commissioned for the financial year 2006
to 2007 per head of population in each former PCT locality
Former PCT
Preston
Chorley & South
Ribble
West Lancashire
Number of
Commissioned
NHS UDAs
06/07
219,027
Number in
Population
Number of UDAs per
head population
131,281
1.67
307,592
209,495
1.47
223,523
109,480
2.04
At present 55 practices in Central Lancashire have contracts with the PCT to
provide NHS primary care dental services. Map 6 in Appendix One shows the
locations of these practices and identifies those, which only treat children under
NHS arrangements.
19
The proportions of the population of Central Lancashire receiving care from dentists
outside Central Lancashire, or the number of non- Central Lancashire residents
receiving care in Central Lancashire are not known. Most Central Lancashire
practices carry out some of their work in the independent sector. The number of
practices operating totally under such arrangements is not known.
The precise number of patients in Central Lancashire, requiring regular dental care,
waiting to be allocated to local dentists is currently unknown, because data are
collected in each former PCT locality using different methods. A conservative
estimate suggests that there are in excess of 5500 patients in such circumstances.
The majority of these live in Preston and Chorley and South Ribble. It is noted that
the PCT is currently commissioning fewer UDAs per head of population in these
areas compared with West Lancashire.
Central Lancashire has a large Salaried Primary Dental Care Service, which has
been created through a merge of the former Preston PCT, Chorley and South
Ribble PCT and West Lancashire PCT services. This merge is still under
development. Nine clinics currently operate across Central Lancashire. These are
shown in Map 6 in Appendix One. These provide access appointments for those
patients requiring urgent care and routine appointments for referred patients. In
addition, special care dentistry, specialist paediatric dentistry and dental services for
phobic patients are provided. Central Lancashire residents requiring extractions, or
in special cases dental treatment under general anaesthesia, are treated at either
Chorley & South Ribble District General Hospital, The Royal Preston Hospital or
Ormskirk & District General Hospital through the Salaried Primary Dental Care
Services.
Recommendations:
16. The PCT should increase commissioning of dental services where there
appears to be inequitable access in high treatment need areas.
17. The PCT should also commission services where there is comparatively
more demand.
18. The PCT should continue to develop the Salaried Primary Dental Care
Services, in collaboration with the Clinical Directors.
20
3.5 Access to dental services for vulnerable patients
Many vulnerable patients have needs, which require special care. A specialty in
Special Care Dentistry is in the process of being formally recognised. Special Care
Dentistry is specifically concerned with promoting equitable oral care to patients with
disabilities and complex needs. These may include physical, sensory, mental health,
medical, emotional or social impairment or disability. Often there is a combination of
a number of these factors.
Some patients with special needs can be treated in primary care through the
General Dental Service. The Department of Special Care Dentistry provided in
Central Lancashire provides comprehensive oral care for both adult and paediatric
patients with a range of special needs. Treatment of these patients occasionally
requires the use of general anaesthesia. One of the sites where this treatment is
carried out in Central Lancashire is in Ormskirk & District General Hospital. There is
currently a long waiting list at this hospital for this treatment.
The introductions of "tool kits" for PCTs that commission specialised services are
useful in formulating specific standards of care. The British Society of Disability and
Oral Health, in its capacity as the specialist society for Special Care Dentistry, was
funded by the Department of Health to develop a tool kit for the Commissioning of
Special Care Dentistry; this has recently been released.
21
Recommendations:
19. The PCT should identify the cause of the long waiting list at Ormskirk &
District General Hospital.
20. The PCT should commission, if appropriate, a waiting list initiative to
reduce the existing length of wait for dental treatment under general
anaesthesia at Ormskirk & District General Hospital.
21. If the cause of the long waiting list cannot be remedied, the PCT should
consider commissioning dental services from another provider.
In
accordance with national guidelines the waiting time for patients from
referral to treatment should be no longer than 18 weeks.
22. Oral care should be incorporated into all health plans for vulnerable groups
where possible.
23. All commissioning decisions with regards to special care dentistry should
be informed by the British Society of Disability and Oral Health
Commissioning Tool.
22
3.6 Prison dentistry
At present the delivery of dental services across the three Central Lancashire
prisons differs. The HMP Preston dental service is provided by the PCT, which subcontracts the provision out to three independent dental contractors on a payment by
session basis. HMP Garth and Wymott operate under the terms of the new general
dental service contract arrangements whereby the independent dental contractor
holds the contract and is required to deliver UDAS for an agreed contractual value.
Both HMP Garth and Wymott currently have one independent dental contractor
providing dental services.
Although security issues can inhibit service provision in all prisons, there are
historical variations between the three prisons in terms of access and delivery of
service. A survey of prisons in Cumbria and Lancashire is currently being
undertaken to identify key oral health and dental service challenges to inform future
development. Some priority areas have been identified and a number of small pilots
are planned to assist in the modernisation of prison dental services.
Recommendations:
24. Following the review currently being undertaken, prison dental services
should be aligned across all three prisons to ensure equity.
25. The PCT should support a modernisation agenda of dental services
across all three prisons.
23
3.7 Central Lancashire Dental Workforce Development
A survey of the dental workforce in Cumbria and Lancashire was carried out in
August 2004. The response rate varied between former PCT areas. The
consequences of a low response rate for Preston PCT mean that the results must
be viewed with caution. Nevertheless, the survey revealed a number of key
workforce issues. These are outlined below:

Workforce composition – the majority of dental service provision was
provided by dentists, although there were hygienists practising in the area
there were very few dental therapists providing services. As dental therapists
can undertake more dental procedures than a hygienist, this would indicate a
lack of skill mix within the workforce at this time.

Dental Nurses – The workforce survey indicated a high percentage of dental
nurses were not qualified, although some experienced dental nurses met
experience equivalence criteria and therefore would be able to register.

Age profile – the majority of dentists were aged 40 years or more (Preston
62%, Chorley and South Ribble 77% and West Lancashire 80%). In the
former Chorley South Ribble and West Lancashire PCT area there were
some signs of recruitment in the younger age bracket (23 – 30 years old) at
10% and 16% respectively. This age profile reflected a lack of ability to recruit
new graduates into the area.
The new Cumbria and Lancashire Dental School based at the University of Central
Lancashire, Preston may assist with future recruitment. This comprises this site and
four outreach-training facilities (Dental Education Centres), which will be, located in
PCTs within Cumbria and Lancashire. These will provide undergraduate dental
education to dental students from September 2007. In addition outreach teaching in
local dental practices and clinics will be required across Cumbria and Lancashire.
Cumbria and Lancashire also currently provides approximately 45 vocational
training places, and trains 18 dental therapists per year. A number of these trainees
have been placed in the Central Lancashire PCT locality.
It is essential an adequate number of training placements are maintained and
developed to meet future training demand. The existing dental workforce will require
appropriate development to make it ready to accept this challenge.
Central Lancashire will be supporting a research project through the Dental Public
Health Department, as part of a project across Cumbria and Lancashire. This aims
to determine the effectiveness of services provided by dental therapists following the
introduction of the new dental contract. This research is being undertaken in
partnership with the University of Liverpool Dental School, and will commence in
September 2007.
24
The PCT is working with the North Western Deanery to develop two levels of
training practices/services to support dental therapy, vocational, undergraduate, and
postgraduate training.
Recommendations:
26. The PCT should commission an update of the Dental Workforce Survey
for Central Lancashire.
27. A workforce plan should be developed to ensure future recruitment and
commissioning is linked to service development.
28. As part of the work force plan the PCT should support the development
of training practices/services in Central Lancashire to meet the training
needs of the future dental workforce.
3.8 Standards
Central Lancashire PCT engages the services of two General Dental Practice
Advisers whose roles involve assessing primary dental service providers’
performance against health standards. Their activities are closely linked to the
PCT’s Clinical Governance Framework. They are also involved in the management
of poorly performing providers.
Both advisers have a programme of dental practice inspections. Environmental
assessments are also carried out by the NHS Business Services Authority Dental
Division.
Recommendations:
29. The PCT must work with the General Dental Practice Advisers to develop
a consistent approach to quality assessment and control across all
providers of primary care dental services.
25
3.9 Access to NHS Secondary and Tertiary Care Dental Care Services
Oral and maxillofacial surgical services are provided for residents of Central
Lancashire by Lancashire Teaching Hospitals NHS Foundation Trust in Preston and
Chorley. From 1st April 2007 children can only receive treatment under general
anaesthesia in Central Lancashire at the Royal Preston Hospital and Ormskirk &
District General Hospital due to the availability of child in-patient facilities.
Those, who require referral for specialist orthodontic treatment, currently access
services provided by Lancashire Teaching Hospitals NHS Foundation Trust or at
one of five specialist orthodontic practices. One of these practices provides a small
amount of orthodontic care to patients who are awaiting orthagnathic surgery, which
is provided at Lancashire Teaching Hospitals NHS Foundation Trust. A small
amount of advanced restorative treatment is also provided by Lancashire Teaching
Hospitals NHS Trust.
The Department of Special Care Dentistry provided at Chorley receives referrals of
patients with complex needs requiring dental care, from either a General Dental or
Medical Practitioner or Consultant colleague. It also accepts referrals from the
Specialist Health Visitor at Broadoaks Child Development Centre and the Looked
After Children's Specialist Nurse. Referrals are accepted at either Ormskirk
Hospitals or the Booking Management Service for Lancashire Teaching Hospitals
NHS Foundation Trust. The unit also acts as a tertiary referral centre, accepting
patients from Consultants at Alder Hey and Royal Manchester (Pendlebury)
Children’s Hospitals, Manchester and Liverpool Dental Hospitals. New patient clinics
are held at Chorley Hospital, Ormskirk Hospital and the Walk in Centre
Skelmersdale. Discussions are currently underway to centralise the referrals for
patients who require access to Special Care Dentistry and Paediatric Dentistry.
The NHS Improvement Plan published in June 2004 set out a new target which
states that by 2008 no one will wait longer than 18 weeks from referral to hospital
treatment. (24)
Recommendations:
30. The PCT should commission a review of secondary care services provided in
its locality, which relate to oral surgery, orthodontics and other dental
specialties.
31. The PCT should re-commission all care currently being undertaken in a
secondary care setting, which could be carried out in a primary care setting,
in a primary care setting.
26
3.10 Access to NHS Unscheduled Dental Care Services
In hours - Preston locality
Provision of unscheduled dental care both in and out-of-hours became the
responsibility of the PCT in April 2006. The former Preston PCT developed a single
point of access for all unscheduled dental care in that all telephone enquires are
dealt with by the Preston dental helpline.
Qualified dental nurses working on this helpline undertake two activities:
1. Emergency dental triage for patients experiencing dental problems. This
signposts patients to the appropriate service.
2. Admission onto an access database for patients seeking routine dental care.
Initial emergency dental treatment is provided from Saul Street Clinic in Preston and
access sessions are commissioned within independent dental contractors. Patients
receiving emergency care, requiring ongoing treatment, are offered further
appointments within the PCT Primary Dental Care Services.
This information system provides the PCT with information, and forms part of the
evidence on which to base future commissioning decisions.
In hours – Chorley and South Ribble and West Lancashire localities
Chorley South Ribble and West Lancashire localities currently do not have a similar
system in place. Emergency care is accessed via NHS Direct and local information.
Emergency in–hours services are provided at Westbank Dental Service, Chorley,
through access slots that are provided as an integral part of clinics that also provide
special care dentistry.
Patients seeking routine care are placed on an access database via the Preston
Dental Helpline and transferred to dental services when clinical capacity becomes
available.
27
Out of Hours
An Emergency Dental Service operates each week day evening, weekends and
Bank Holidays.
Preston residents access out-of-hours dental services from Royal Preston Hospital
via the helpline as described above.
Out-of-hours dental services are provided for the residents of Chorley, South Ribble
and West Lancashire on alternate weeks from Chorley & South Ribble District
General Hospital and Skelmersdale Walk-in Centre, through NHS Direct and local
information.
Due to operational and managerial constraints the provision of out-of-hours dental
services within secondary care settings has raised some concerns.
Recommendations:
32. The PCT should align all unscheduled dental care services to utilise
current expertise and provide a seamless service.
33. A single point of contact should be developed to provide consistency
for service users.
34. The PCT should commission in and out of hours unscheduled care
based on locality demand.
35. A review of the current, potential, and the setting of unscheduled
service provision should be undertaken.
28
Appendix One
Map 1
29
Map 2
Higher statistics represent more deprived
30
Map 3
31
Map 4
32
Map 5
33
Map 6
34
Map 7
35
Appendix Two
Average dmft of 5-year-old children
3.00
Chorley & South Ribble
North West
England
2.80
2.60
2.40
Average dmft
2.20
2.00
1.80
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
1991/92
1993/94
1995/96
1997/98
1999/2000
2001/02
2003/04
2005/06
The Dental Observatory
Percentage of 5-year-old children with decay experience
70
Chorley & South Ribble
North West
England
65
60
55
Percentage
50
45
40
35
30
25
20
15
10
5
0
1991/92
1993/94
1995/96
1997/98
1999/2000
2001/02
2003/04
2005/06
The Dental Observatory
36
Average dmft
Average dmft of 5-year-old children
4.00
3.80
3.60
3.40
3.20
3.00
2.80
2.60
2.40
2.20
2.00
1.80
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
Preston
North West
England
1991/92
1993/94
1995/96
1997/98
1999/2000
2001/02
2003/04
2005/06
The Dental Observatory
Percentage of 5-year-old children with decay experience
80
Preston
North West
England
75
70
65
60
Percentage
55
50
45
40
35
30
25
20
15
10
5
0
1991/92
1993/94
1995/96
1997/98
1999/2000
2001/02
2003/04
2005/06
The Dental Observatory
37
Average dmft of 5-year-old children
3.00
West Lancashire
North West
England
2.80
2.60
2.40
Average dmft
2.20
2.00
1.80
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
1991/92
1993/94
1995/96
1997/98
1999/2000
2001/02
2003/04
2005/06
The Dental Observatory
Percentage of 5-year-old children with decay experience
65
West Lancashire
North West
England
60
55
50
Percentage
45
40
35
30
25
20
15
10
5
0
1991/92
1993/94
1995/96
1997/98
1999/2000
2001/02
2003/04
2005/06
The Dental Observatory
38
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40