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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 Reference List (1) Central Lancashire Primary Care Trust web site. 27-1-2007. (2) Department of Health. Choosing better oral health: An oral health plan for England. 2005. Department of Health. (3) Health and Social Care (Community Health Standards) Act 2003. 2003. London, The Stationary Office. (4) Chief Dental Officer (England). NHS Dentistry: Delivering Change. 2004. London, Department of Health. (5) Department of Health. Our health, our care, our say: a new direction for community services. 2006. Department of Health. (6) Department of Health. Commissioning for Health and Wellbeing . 6-3-2007. Crown. (7) Peters J, Abbas F, Mechan J. Profile of Central Lancashire Local Authorities. Preston: Preston Primary Care Trust, 2006. (8) Tickle M, Kay E, Worthington H, Blinkhorn A. Predicting population dental disease experience at a small area level using Census and health service data. J Public Health Med 2000; 22(3):368-374. (9) Sweeney P, McCall D, Nugent Z, Pitts N. Scottish Health Boards' Dental Epidemiological Programme: Deprivation and Dental Caries. 1996. Dental Health Services Research Unit, University of Dundee. (10) Pine C, Burnside G, Craven R. Inequalities in dental health in the north-west of England. Community Dent Health 2003; 20(1):55-56. (11) Lancashire County Council Environment Directorate. People in Lancashire with a Limiting Long-Term Illness. 2003. (12) Lancashire County Council. Adults aged 18-64 with physical disabilities helped to live at home: PAF 29. 2005. (13) Lancashire County Council. Adults aged 18-64 with learning disabilities helped to live at home: PAF C30. 2006. (14) Lancashire County Council. Older people helped to live at home: PAF C31. 2006. (15) Lancashire County Council. Admissions of supported residents aged 65 or over to residential/nursing care: PAF C26. 2006. 39 (16) Lancashire County Council. Health of Children Looked After - District Report: PAF C19. 2005. (17) Lancashire County Council Environment Directorate. Homelessness in Lancashire. 2006. (18) North West Public Health Observatory. Local Health Profiles. 2006. (19) Community Oral Health. Oxford: Wright, 1997. (20) Daly B, Watt R, Batchelor P, Treasure E. Essential Dental Public Health. New York: Oxford University Press, 2002. (21) Levine R, Stillman-Lowe C. The scientific basis of dental health education. Community Dent Health 2002; 19(2):127. (22) Levine R, Stillman-Lowe C. The scientific basis of dental health education. Community Dent Health 2002; 19(2):127. (23) British Dental Association. 2009 - What does it mean? 2007. (24) Department of Health. The NHS Improvement Plan: Putting People at the Heart of Public Services. 24-6-2004. Crown . 40