Oral Dental Health Needs Assessment for NHS Norfolk. Oral Health Needs Assessment. NHS Norfolk

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1 Oral Health Needs Assessment NHS Norfolk

2 Summary Population, epidemiology and prevention Everybody needs access to quality dental care and Norfolk s population is set to increase by over 10% in the next decade, with relatively larger increases in adult and older age groups than among children There are already higher proportions of older people in Norfolk, particularly North Norfolk than in England generally and there is a seasonal influx of tourists, who sometimes require unplanned dental care Ethnic groups are in lower proportions than seen elsewhere in the country and there is a risk that there is a lack of general awareness of specific cultural or language needs or information services to support these groups There is an association between deprivation and poor oral health which is evidenced repeatedly by local and national survey work There are areas of deprivation in parts of Norfolk concentrated mainly in Kings Lynn, Norwich, Thetford and Great Yarmouth Targeted health promotion and drop in styles health services are recommended in areas where deprivation is most concentrated Oral disorders and epidemiology Most dental diseases are completely preventable, but when they occur they can have life long effects which require continued professional input Investment in oral health promotion and prevention is reasonable as many risk factors for oral disease are shared with other health conditions and combining health promotion initiatives is recommended In Norfolk joint prevention initiatives include Health Trainers, Change 4 Life, Lets Get Moving and Good 4 You Dental health of children has improved enormously in recent years with well over half having no decay Higher disease levels are increasingly concentrated among lower income groups but they may also be seen across the wider population Local survey results have continued to show that much dental decay amongst children remains untreated and there is a variety of reasons for this There is evidence that higher socio economic groups are more likely to seek dental treatment and that people who seek dental treatment only when they have a problem are more likely to be from a more vulnerable background Factors affecting oral disease approaches to prevention Key risk factors for oral disorders (dental decay, dental erosion, gum disease, oral cancers, and dental trauma) are poor diet, poor oral hygiene, tobacco and alcohol use and risk of oral injury This would as previously suggest there is a place for oral health promotion within generic health promotion Specific evidence based oral health promotion services are beneficial and cost effective if directed appropriately to particular population groups Linking oral health to other prevention services including other health and social care services will also produce a greater effect The current dental contract is designed to give dentists enough time to use preventive techniques and dental health professionals should be encouraged and supported to apply these

3 The use of water fluoridation at appropriate levels can be protective against dental decay and is recommended by the Department of Health for high-need populations But support with lifestyle choices such as regular brushing with fluoridated toothpaste can also reduce risk for the individual Access to dental services A useful framework for investment in oral health, set out by Professor Steele in his independent review of dentistry in 2009, describes a fundamental requirement for urgent care and pain relief, followed by personalised disease prevention, high quality routine dentistry, continuing care and lastly, advanced and complex care This model of care should be applied across dental provision There is a wide variety of oral health services locally but little overview of how they integrate to provide a population based system A strategic approach to service planning is recommended The uptake of dental services across Norfolk is currently just below the target of 63% of the population NHS Norfolk is commissioning additional activity to improve this performance NHS Norfolk is working with providers to ensure that frequency of recall intervals for checkups is in line with best practice guidance from the National Institute of Health and Clinical Excellence The evidence base upon which dental services in England is published in Delivering Better Oral Health (DH) and services should be shaped locally to meet need, responding in particular to the needs of vulnerable patient groups and recognising increasing diversity in Norfolk s population Good information needs to be available on oral healthcare and local services for all population groups Most (83%) dental prevention and treatment takes place through general dental services with 10% targeted at more vulnerable clients which is provided through salaried providers Current primary care contract information NHS Norfolk has 98 contracts with 82 providers, spread across the county This delivers over 13 million units of dental activity per year, with a baseline contract value of 323M; the average UDA rate being 2385 Strategic development has focussed on ensuring access in major and market towns and their surrounding areas New providers are building up to full capacity with further investment planned Orthodontic care historically has had long waits to start treatment Recent investment in services has taken place and referrals are now centralised through a referral management service This enables monitoring and promotion of choice for patients to access services from a range of providers Care for anxious patients depends on specific needs and much of the care locally for adults is delivered through one large provider Referral pathways and guidelines are being developed as part of a review of services for anxious and phobic patients Just over one thousand patients were treated on a domiciliary basis in 2009/10 through general dental services, mainly through a single provider Provision is currently being reviewed Urgent access to care during normal clinical hours is provided at Kings Lynn and Norwich for patients who access dental care only when they need it or patients who have problems accessing their own dentists Between the two centres, nearly one thousand four hundred people are seen per month In addition, other dental practices provide some appointments and sessions which need to be clearly advertised to patients There is an out of hours dental

4 service, accessed by telephone, for urgent problems, although some patients do try the GP out of hours service or attend the Accident and Emergency departments Special care dentistry is more appropriate for some individuals and most services are based in Norwich and Kings Lynn, but there are other clinics that operate part time around the county Work needs to be done to establish the best pathways for care for patients who need these services and to promote integrated working between salaried and general dental services The patient voice Uptake of NHS dental services is relatively high within the Eastern Region and regional surveys have shown that there have been no significant issues of dissatisfaction with services in Norfolk in comparison to other areas However, when judged on access and flexibility of appointments, the services in Norfolk are ranked below average This position may have got worse and NHS Norfolk is planning work to improve this by pro-actively marketing any future service development Main Issues Link oral health to other prevention initiatives Develop a strategic approach to service planning for oral health Drive up quality and support the dental profession to embrace changes Offer flexible services Ensure services are efficiently provided The public, patients and carers need good information about dental health Please note there is also a separate Executive Summary and Commissioning Intentions Action Plan Document which is an addendum to this document,

5 Introduction, aims and objectives Oral Dental Health Needs Assessment for NHS Norfolk A healthy mouth is integral to general health and wellbeing, allowing people to eat, speak, and socialise without active oral disease, discomfort or embarrassment Dental decay and gum disease remain widespread across the population, costly to treat but preventable Hence they are public health issues Since the introduction of fluoridated toothpaste in the 1970s, there have been large reductions in tooth decay but not everybody benefits equally Population averages mask oral health inequalities and oral disease levels reflect gender, age, ethnicity, geographic location and socio-economic group and there is strong evidence that dental disease is increasingly concentrated among socially disadvantaged groups Most people use dental services and Primary Care Trusts are required by the Department of Health to have a strategic approach to planning as set out in Improving dental access, quality and oral health (2009), and a statutory duty to provide oral health services to meet local needs Standards are set out in Choosing Better Oral Health an Oral Health Plan for England (2005) and supported and further developed by later publications such as Delivering Better Oral Health (2007) with further recommendations made in The (independent) Steele Report (2009) Regional priorities are described in terms of twelve pledges (Towards the best Together 2006) Two of these East of England Pledges apply specifically to dentistry: pledge 4 We will ensure that NHS Primary dental services are available locally to all who need them and pledge 2 We will extend access guarantees to more of our services, where it was agreed that primary care based orthodontic services would be one of these services Further, Pledge 9 states that we will ensure healthcare is as available to marginalised groups and looked after children as it is to the rest of us Dentistry is explicit in the Joint Strategic Needs Assessment Plan for NHS Norfolk, Bold and Ambitious (2009) and significant commissioning has already taken place, informed by a series of local needs assessments through the JSNA, overseen by the PCT Board (December 2009) It is now timely to revisit our local needs assessment, identify successes, good practice, inefficiencies and gaps to inform commissioning decisions for the PCT Operating Plan 2010 and for the years beyond Dental commissioners at NHS Norfolk are committed to this refreshed needs assessment for use as the organisational changes, described in the White Paper, Liberating the NHS, take place Changes include the abolition of PCTs and the establishment of a National Commissioning Board and Public Health Service, with the Local Authority taking the strategic lead locally, supported by a public health team Dental services will be commissioned through the National Commissioning Board The dental contract (for General Dental Services) will be replaced, but only after a pilot, by a successor contract to be published in December 2010, when the White Paper on Public Health is also expected Recommendations from this needs assessment will reflect core values of NHS Norfolk, including respect for diversity within the population and the need for equity across the whole population, taking account of the recent independent review on health inequalities NHS Norfolk acknowledge: The Marmot Review (2010) NHS Norfolk acknowledge Jennifer Donaghy, specialist trainee in Dental Public Health, who produced the original literature reviews, which we updated and adapted to be relevant to Norfolk in 2010

6 Aims To undertake a dental health needs assessment for Norfolk, establishing a shared understanding of dental health the roles, current provision and costs of publically funded dental services views of the public, patients and professionals evidence upon which prioritising for future investment, disinvestment and development can be done Objectives 1 To understand the demographics of Norfolk 2 To describe key oral diseases and disorders and their impact across the whole population 3 To understand what can be done to prevent oral disease 4 To describe current service provision, pathways into care, costs and outcomes 5 To review feedback received through PALs and complaints 6 To consult with the dental profession through the Local Dental Committee and the Oral Health Advisory Group 7 To make supported, evidence based and costed recommendations to NHS Norfolk on priorities for investment and for saving

7 Processes and data sources Process: The process of this exercise is shown diagrammatically below: Demographics, epidemiology and prevention (Lead: Public Health) Professional overview, actual and potential patient pathways, quality and professional issues (Lead: Oral Health Advisory Group) NHS Services, budgets, costs, quality, capacity and pressures (Lead: Contracting Team) Describing met and unmet need (Gap analysis) and defining priorities (Lead: Dental Needs Assessment Team) Draft evidence based document for consultation with PEX/LDC/OHAG/PCT/Local Authorities Delivery of PCT statutory functions: population screening, surveys and prevention programmes Commissioning activity and monitoring Clearer pathways to, and appropriate use of, specialised services Better geographical spread of primary care services, meeting current quality standards and more information about them Increased capacity to see and treat irregular attendees and to address inequality of access

8 Overview of key data and reference sources: Demographics, epidemiology Nationally published ONS population data ONS National dental surveys Local dental surveys, coordinated nationally (BASCD surveys) The English NHS Dental Epidemiology Programme Local information from the Norfolk Joint Strategic Needs Assessment (JSNA) Prevention of dental disease Choosing Better Oral Health An Oral Health Plan for England (Gateway 4790) (Department of Health 2005) Statutory Instrument (2006) Delivering Better Oral Health (Department of Health 2007) Primary care and community services: improving dental access, quality and oral health (Department of Health 2009, (Gateway 11000) Pathways and quality NICE guidance on extraction of Wisdom Teeth and on Recall interval Project work with the Norfolk Oral Health Advisory Group (2009 and 2010) Improving dental access, quality and oral Health (World Class Commissioning) Building Relationships: dental contract management handbook (Primary Care Commissioning) 2010 Improving oral health and dental outcomes: developing the dental public health workforce in England (March 2010) NHS dental services in England: an independent review led by Professor Jimmy Steele, 2009 Local primary and secondary care service information Contract information from e Reporting Contract monitoring of salaried dental services Secondary care information from the HES database Local Audit of referral management centre data Local Audit of sedation services Local Audit of calls to A&E and out of hours GP services Local Audit of PALs enquiries and complaints of the past 12 months Outline document design and baseline literature review Oral Health Needs Assessment, NHS Hertfordshire 2008

9 Contents Oral Dental Health Needs Assessment for NHS Norfolk Part 1: Population, epidemiology and prevention Section 1: Population and Demography of Norfolk 11 Demography and trends 12 Ethnicity 13 Deprivation in Norfolk Summary points Section 2: Common Oral Disorders and epidemiology 21 The disorders dental decay (caries) gum (periodontal) disease, oral cancer malocclusion and orthodontics 22 Oral Health and inequalities in Children Dental Caries Cleft Lip and Palate Orthodontic Treatment Need 23 Oral Health and inequalities in Adults Dental Caries Gum (Periodontal) Disease Oral Cancer in Adults Summary points Section 3: Factors affecting oral disease and approaches to prevention 31 Biological and Social Determinants 32 Using the Common Risk Factor Approach to tackle inequality Diet Overweight and Obesity Smoking Alcohol misuse Drug misuse 33 Populations in special situations Summary points Section 4: Prevention Services 41 Water Fluoridation 42 School dental inspections 43 Dental Check ups 44 Oral Health Promotion Summary points Part 2 Dental Care Pathways, services in Norfolk, gaps, efficiencies and productivity Section 5: Dental Care Pathways 51 Overview of system 52 Current Pathways for dental care in Norfolk 53 Overall spend Summary points Section 6: Current primary care contract information 61 General dental services 62 Current contracts location of services, activity and feedback through PALS 63 Local Orthodontic service provision current contracts, activity, referrals 7

10 Contents Oral Dental Health Needs Assessment for NHS Norfolk 64 Local Sedation services provision current contracts 65 Local Domiciliary services provision current contracts 66 Local Access services provision current contracts 67 Local Special care services provision current contracts Summary points Section 7: Secondary care and referral management 71 Hospital out patients 72 Daycases, emergency and elective 73 Referral management Summary points Section 8: Public Voice 81 National Surveys 82 Regional Surveys 83 Local Surveys 84 Reports from PALs and complaints Summary points Section 9: Figures & Tables References 8

11 Part One: Population, epidemiology and prevention Section 1: Population and Demography of Norfolk Norfolk overview Most people use dental services NHS Norfolk had a population projection of for mid 2010, increasing by around 10% over the next decade General public health issues that relate to oral health are smoking and obesity Smoking prevalence rate is 194%, lower than the England average and has reduced in recent years There still remains, however, smokers 1 in 5 adults are obese and the number of diabetics is increasing A role for all dental services is to provide smoking cessation advice and dietary advice On average, men and women in NHS Norfolk live longer than the average in England Rates of early death from heart disease, stroke and cancer have fallen over the last decade and are lower than the England average Estimated deaths from smoking in Norfolk are 1400 per year, a rate of 1722 per , a good deal lower than the rate of 2068/ across England Across the Anglia Cancer Network there are just over 400 new cases of oral cancer registered per year Older people today are likely to have complex dental care needs due to disease and treatment patterns earlier in their lives Younger populations have different care needs, often with less experience of dental decay but the need for long-term maintenance of a healthy mouth 11 Demography and trends Figure 1 illustrates population increases that have already taken place in NHS Norfolk between 2002 (the bars) and mid 2008 (the lines) and hence potentially put pressure on existing dental services Data on this six year time interval show that by the end of this period there were, for example, nearly extra people aged 65 and over, of whom were aged 80 and above 9

12 Figure 1 Recent population increases in Norfolk (Mid , ONS) Age (5 year bands Total estimated resident population by age and sex, NHS Norfolk population growth, mid-2002 compared mid 2008 population Population 2002 Females 2002 Males 2008 Females 2008 Males Population projections over the next decade in Norfolk, shown in Figure 2, anticipate further increases of over 10% across all age groups, with greatest increases among year olds and year olds, and with those in their fifties not far behind This is relevant in that people under forty are more likely to have dental health and a low treatment need, whereas older people today are likely to have past treatment for dental disease that requires maintenance Very few people today are edentulous (ie with all teeth having been extracted in the past) Figure 2: Population projections for Norfolk: 2010 and 2020 (source: ONS) Changes in Norfolk population between 2010 and Number of persons 10

13 Looking specifically at children, Norfolk in 2010 has approximately 181, year olds The largest rise within this age group over the next ten years is among 5 to 9 year olds, from 41,828 to 52,793 (an extra 10,985, an 18% rise) by 2020 This will be partially offset by a drop of about 7% of year olds, currently estimated at nearly to The recent Children s Dental Health Survey in 2003 found that 35% of 12-year-olds in England would benefit from orthodontic treatment i This figure is often used to plan commissioning of orthodontic services, with the caveat that not all of these children will seek, accept or be suitable for orthodontic treatment In Norfolk there are approximately 9, year olds and this number has reduced in recent years and is projected to reduce further over the next few years This is revisited in the last part of Section 22 on orthodontic treatment need The graphs below (Figure 3) show the distribution of the young population by age band by district in 2008 Location of services should anticipate this distribution, alongside the distribution of the oldest members of society, illustrated next, as both groups will have a proportion unlikely to travel far for routine care, whereas working age adults often commute to a town or city for employment and recently retired people for leisure and other services and may prefer to access their care there 11

14 Figure 3: males and females 0 19 by District in Norfolk (ONS data, 2008) 18,000 Number of Males aged 0-19 by age band, gender, and district for Norfolk, 2008 (source: ONS) 16,000 14,000 12,000 10,000 8,000 6, ,000 2,000 0 Breckland Broadland Great Yarmouth King's Lynn and West Norfolk North Norfolk Norwich South Norfolk Number of Females aged 0-19 by age band, gender, and district for Norfolk, 2008 (source: ONS) 18,000 16,000 14,000 12,000 10,000 8,000 6, ,000 2,000 0 Breckland Broadland Great Yarmouth King's Lynn and West Norfolk North Norfolk Norwich South Norfolk It is particularly important that across all districts services are proportionate for all age groups Figures 4 and 5 compare proportions (ONS mid year projections for 2010) of people aged sixty five and over and eighty and over respectively in the districts within Norfolk and with the Norfolk and England averages For both age groups, the proportions are largest in North Norfolk, where those aged 65+ approach 30% (the largest proportion in the country) with over 8% aged eighty or over For all districts 12

15 except Norwich, the proportion is over 5% more than the England average (65+) and over 1% more (80+) Figure 4: Proportion of Population 65+ Proportion of the population aged 65+ (by District) ONS 2010 projections 300% 250% % population 200% 150% 100% % 65+ Norfolk 65+ England % 00% Breckland Broadland Great Yarmouth King's Lynn and West Norfolk North Norfolk Norwich South Norfolk Figure 5: Proportion of Population 80+ Proportion of the population aged 80+ (by District) ONS 2010 projections 90% 80% 70% 60% % population 50% 40% 30% % 80+ Norfolk 80+ England % 10% 00% Breckland Broadland Great Yarmouth King's Lynn and West Norfolk North Norfolk Norwich South Norfolk Figure 6 maps the proportions of people aged sixty five and over These age groups frequently live in rural and remote areas of Norfolk although some live in urban areas 13

16 Figure 6: Map showing Proportion of Population 65+ in Norfolk Seasonal population increases Norfolk has a thriving tourist industry which brings in temporary residents, particularly in the summer months The implication for dental services is that these people might need urgent care whilst away from their regular services The compendium of tourism statistics identifies the following numbers of tourists visiting Norfolk in the years : Table 1: numbers of tourists to Norfolk and nights stayed (Source: Tourist office) Year Norfolk staying trips (ie not day trips) (millions) Norfolk: nights stayed Ethnicity The specific needs of many minority groups are increasingly being identified England has a much higher ethnic diversity than Norfolk Ethnic groups in Norfolk have a much lower profile than in other areas and hence there is an increased risk that their needs can be overlooked Data is insufficiently accurate to map the distribution of this small and diverse population that includes academics, employed and self employed, migrant workers, and travelling families 14

17 Figure 7a: Estimated Ethnic composition of England, 2007 mid year estimate (ONS Experimental Statistics) Mixed 2% Asian 6% Black 3% Chinese or other 1% White Other 3% White Irish 1% White British 84% Figure 7b: Estimated Ethnic composition of NHS Norfolk (residents), 2007 mid year estimate (ONS Experimental Statistics) White Irish 1% White Other 3% Mixed 1% Asian 1% Black 1% Chinese or other 1% White British 92% In NHS Norfolk, the proportion of ethnic groups has changed significantly since the Census in 2001 The results from the 2001 Census showed NHS Norfolk to have a majority White British population (9847%) and a very small minority of people of a non-white British population (153%) Since 2001, the non-white British population 15

18 had been estimated to have doubled in NHS Norfolk to approximately 31% of the general population NHS Norfolk has also experienced a net gain in the number of migrant workers coming from Europe to work and live since the 2001 Census The settlers from Poland, Lithuania, Portugal, and Latvia often have complex needs in terms of accessing healthcare services relating to cultural differences and communication The health needs of these groups have not been well investigated 13 Deprivation in Norfolk Deprivation is an important consideration when assessing needs for local dental services It has been shown to be strongly associated with dental ill-health; for example children living in more deprived areas experience more dental decay (Tickle et al, 2000) This is explored in more detail in Section 2 on oral disease It must also be appreciated that there may be differences in interest and priority for routine dental care for people with more deprived circumstances and they may need different approaches to tackling their problems The Index of Multiple Deprivation (IMD) 2007 provides a summary measure of deprivation for each of small geographical areas in England, called lower super output areas (LSOAs) Each area has around 1,500 people and data can be combined to provide scores for larger areas such as current electoral wards There are 3,550 LSOAs in the East of England, 530 in Norfolk and 469 in NHS Norfolk The reader is referred to the following website for more information: Essentially, for each small geographical population group, deprivation is scored across seven domains, containing a number of indicators which are weighted and combined The domains and weights are shown in Table 2, with emphasis on money, health and education Scores are combined to middle layer super output level across Norfolk as shown in Figure 8, where the map shows deprivation to be concentrated in Kings Lynn, Norwich, Thetford and Great Yarmouth areas, with wider areas around the coastal areas particularly in the North and West Conversely, least deprivation surrounds Norfolk, across Broadland and areas of Southern Norfolk and Breckland Table 2: Domains of multiple deprivation and their weights Domain name Weight used in index Income deprivation* 225 Employment deprivation 225 Health deprivation and disability 135 Education, training and skills deprivation 135 Barriers to housing and services 93 Living environment deprivation 93 Crime 93 * There are two supplementary indices: Income deprivation affecting children Income deprivation affecting older people 16

19 Figure 8: Deprivation in Norfolk Comparing deprivation: quintiles Nationally, LSOA areas have been ranked 1 32,482 according to IMD score; 1 represents the most deprived The list has then been divided into five quintiles of 6496, the top quintile (1) being the 20% most deprived and the bottom (5) being the 20% least deprived Figure 9 shows the distribution in Norfolk and NHS Norfolk of our LSOAs according to national quintile; across the Nation, all the bars would be of equal length Locally, we see the commonest quintiles to be average (3) or above (4 or 5) Figure 9: Number of LSOAs for Norfolk and NHS Norfolk in each national deprivation quintile Number NHS Norfolk Norfolk (Most deprived) (least deprived) National deprivation quintile (IMD 2007) 17

20 Norfolk has 56, and NHS Norfolk, 39 LSOAs in the most deprived 20% (quintile) of 6,496 LSOAs (1) The national picture for this quintile is that just over a third of the people are income deprived, one in five of women aged and men aged are employment deprived and just under half of children live in families that are income deprived and nearly 40% of older people income deprived It is to be noted, however, that most of these 6,496 LSOAs in the lowest quintile nationally are in the North East and North West of England; our local areas number among only 223 found in the East of England and so their collective characteristics may be different Health promotion initiatives are already targeted in these most deprived areas, and it is recommended that dental issues should be dealt with alongside Additionally there should be easy access to drop in style dental services for more deprived areas Eighty three of Norfolk s LSOAs fall into the least deprived quintile (5) (again 6496 LSOAs nationally) These 83 are all within the boundary of NHS Norfolk The numbers of LSOAs within the worst and least deprived national quintiles are summarised in Table 3 and are important to inform our consideration of health inequality within districts Table 3: Worst and least deprivation by district (measured by IMD 2007) District Number LSOAs in most deprived 20% (6496)LSOAs nationally Number LSOAs in least deprived 20% (6496) LSOAs nationally Great Yarmouth 17 0 Norwich 28 8 Kings Lynn and W Norfolk 9 9 North Norfolk 1 2 Breckland 1 9 South Norfolk 0 24 Broadland 0 31 Norfolk Despite this ranking of very small areas, there is no standard comparison or description of larger areas such as local authorities, other than ranking, because of the range of indicators that contribute Overall rankings for the seven districts of Norfolk out of the 354 in England are shown in Table 4, with Norfolk itself ranking 97 out of 149 counties, ie almost within the top third, hence well below average overall deprivation It would appear that a good range of standard NHS dental services would be a wise approach to catering for this majority Table 4: IMD score and rank of Norfolk districts within 354 in England District (1 = most deprived) Rank of average score Great Yarmouth 58 Norwich 62 Kings Lynn and W Norfolk 137 North Norfolk 160 Breckland 213 South Norfolk 286 Broadland

21 Exploring inequality in further detail, LSOAs in each district can be categorised by the national quintile into which they fall such that the distribution can be seen and compared (Figure 10) Figure 10: Number of LSOAs in each national quintile by district Number of LSOA by national deprivation quintile for each district in Norfolk (IMD 2007) (Most deprived) (least deprived) 32 Number Breckland Broadland Great Yarmouth King's Lynn and West Norfolk District North Norfolk Norwich South Norfolk Broadland is the least deprived area overall, and Norwich the most deprived Within each area, however is a wide range of circumstances of residents and service planners and providers should be mindful of this and cater for a range of needs Mental Wellbeing Wellbeing is related to overall health (section 3) There is now a child wellbeing index, along the lines of the IMD index Scores for 2009, for the seven Norfolk districts among 354 English districts are shown in Table 5, where 1 is maximum wellbeing Area Table 5 Index for child wellbeing (2009) Source: Public Health,, NHS N Child Wellbeing index Rank within 354 districts nationally* (1 is maximum wellbeing) Broadland South Norfolk Breckland North Norfolk Kings Lynn and W Norfolk Great Yarmouth Norwich Norfolk* * *Norfolk ranks 58 out of 149 counties nationwide 19

22 The seven domains that contribute to the scores are material well-being, health, education, crime, housing, environment and children in need Children in Norwich, collectively, have a much lower experience of wellbeing than in most other parts of the county according to this index This has not been directly related to oral health, but will contribute generally to the social determinants of health dealt with in more detail in Section 3 20

23 Summary points Section 1 Demographics and dental care needs Everyone needs access to dentistry There is currently a population of 766,900 people in NHS Norfolk, increasing by over 10% over the next decade with largest increases among 30 to 34 and 70 to 74 year olds Anticipated increases in the numbers of children are relatively lower than for the rest of the population (increase of 8%) and the number of 12 year olds, the age where orthodontic treatment is usually planned, will fall slightly, indicating that current services, if adequate now, will have capacity to meet needs for the foreseeable future All districts bar Norwich have higher proportions of older people than England or Regional averages, North Norfolk particularly so It is important to recognise this while commissioning for the whole age spectrum There is an important tourism industry that brings in people who may have urgent dental care needs, particularly in summer months Ethnicity and dental care needs Ethnic groups make up a much smaller (hence at greater risk of being overlooked) proportion of the population in Norfolk, compared to England The proportion is increasing Enabling access to dental care across the wide range of circumstances for ethnic groups (for example, migrant workers and their families compared to families who have lived in Britain for many years) will require a proactive approach from providers (some of whom are, themselves migrant workers) that includes better understanding of the use of translating/interpreting services and tailored approaches where other specific barriers are identified Deprivation and dental care needs There is an association between deprivation and poor oral health, evidenced repeatedly by local and national survey work The index of multiple deprivation provides an objective measure for geographical areas with a population as small as 1, 500 people; these can be ranked but scores do not necessarily provide a blanket description to cover issues specific to any individual community and within each local area these are individuals and families with varying circumstances Mapping deprivation by this index highlights concentration in Kings Lynn, Norwich, Thetford and Great Yarmouth Conversely, least deprivation surrounds Norwich, covering Broadland and areas of Southern Norfolk and Breckland Many areas fall into the median quintile of deprivation when compared nationally, and overall the county tends towards relative affluence and not deprivation Targeted health promotion and drop in style health services are recommended where deprivation is most concentrated Across all other areas a standard range of NHS dental services is recommended that are flexible to meet varying need, particularly the demographics outlined earlier, and also for vulnerable groups, described in Section 3 21

24 Section 2: Common Oral Disorders and epidemiology 21 The disorders Dental Decay (Caries) Dental decay is completely preventable but one of the most common chronic diseases It occurs when tooth tissue is demineralised by the acids formed by dental plaque in response to dietary sugars and is treated by professional removal of the damaged dental tissue and restoration of the tooth (filling, endodontic treatment and possibly fitting a crown to restore function), or else removing the whole tooth (extraction) and replacing with a bridge or denture Evidence has consistently shown that sugars are the most important factor in caries development ii Free sugars include all monosaccharides and disaccharides as well as those naturally present in honey, fruit juices and syrups ii1 and these can cause the harm The annual consumption of free sugars has increased since the 1970s iii The sugars naturally present in whole fruits, vegetables and milk are thought not to be harmful to dental or general health Evidence on prevention of dental disease is presented in Choosing Better Oral Health (Department of Health, 2005), delivered through the common risk factor approach, described below Gum (Periodontal) Disease Gum or periodontal disease is preventable, caused by inflammation of the gums and bone that support and anchor teeth When severe, the bony support for teeth is extensively compromised causing otherwise healthy teeth to be lost The cause of this disease is poor plaque control (tooth brushing technique), exacerbated by smoking, certain systematic diseases (such as Diabetes), genetic factors and stress There is an association with social deprivation and prevalence increases with age There are a number of gum (or periodontal) diseases; however the disease with public health implications is chronic periodontitis in adults Chronic periodontitis can cause bleeding gums, loss of periodontal attachment, recession of gums, periodontal abscesses, drifting of teeth, tooth mobility and ultimately tooth loss These symptoms can have a significant impact on the individual ranging from halitosis and discomfort to changes in appearance and loss of function iv Evidence on prevention of periodontal disease is found in Choosing Better Oral Health (Department of Health, 2005), delivered through the common risk factor approach, described below Oral Cancer Oral cancer is a generic term that is used to describe all malignancies of the oral cavity, oropharynx and hypopharynx (such as squamous cell carcinoma of the lip and tongue) Almost all oral cancers are thought to be preventable An estimated 80% are caused by tobacco (smoking or chewing), alcohol or a combination of the two Although tobacco and alcohol are independent risk factors, their combined effect is greater than the sum of the risks from exposure to either on its own v An estimated 10 15% of oral cancers may be caused by unhealthy diets vi There have been about 414 new cases per year across the Anglia Cancer Network that includes Norfolk, Suffolk and Cambridge Oral cancers are more prevalent amongst deprived populations and often they present late into the healthcare system, demanding more radical treatment and 22

25 shortening life expectancy Prevention and earlier detection are aims to strive for, using the common risk factor approach, described in Section 3 Malocclusion and Orthodontics Malocclusion is not a disease but the collective term given to natural variations from the ideal in the relationships of the teeth and jaws Its presence is not synonymous with a need for treatment vii There is a lack of evidence to suggest that malocclusions have a detrimental effect on oral health, although by affecting facial appearance malocclusions can have an impact on psychological well-being and quality of life viii Because malocclusion is not a disease and orthodontic treatment carries risks (eg root resorption, decalcification and non-improvement) xvi it is particularly important to evaluate the risk-benefit balance of any possible treatment In the UK, need for orthodontic treatment in the NHS is assessed using the Index of Orthodontic Need (IOTN) The IOTN incorporates both an aesthetic and dental health component Both of these aspects of a malocclusion are clinically assessed to determine whether a patient is likely to benefit from treatment The clinician assigns a dental health component grade of treatment need between 1 and 5 (with 5 representing greatest need) and an aesthetic component grade of treatment need between 1 and 10 Under the current regulations, a patient is entitled to NHS orthodontics if their malocclusion has been graded as follows: ix Grade 4 or 5 of the Dental Health Component of the Index of Orthodontic Treatment Need Grade 3 of the Dental Health Component of that Index with an Aesthetic Component of 6 or above Nationally about 35% children aged 12 have an IOTN of 36 or above NHS Norfolk has a policy with acute providers that consultant lead hospital care treats only the dental health component 4 and 5 22 Oral health and inequalities in children The dental health of children has improved enormously since the 1970s; however, population averages mask oral health inequalities A well-recognised association exists between socio-economic status and oral health, and trends suggest that disease is increasingly concentrated in the lower income groups Dental caries In the UK data on dental caries is regularly collected to allow trends in dental disease to be monitored Key surveys that provide information on trends in oral disease at a national level are the decennial Children s Dental Health Survey and the British Association for the Study of Community Dentistry (BASCD) surveys of children s teeth The latter are analysed at a local level and are now run by the NHS through the North West Public Health Observatory Local contribution to survey work is a Statutory Function of a PCT and therefore must be commissioned The expertise usually lies within the salaried dental service hence they are the usual provider Dental caries is commonly measured using the dmft index, which is a record of the number of decayed, missing and filled teeth (dmft) By convention, upper case dmft is used to denote permanent teeth (DMFT) while lower case dmft is used to denote primary teeth The prevalence of dental caries in children has decreased substantially over the past 40 years (Figure 411) The greatest improvement in the decay experience of five- 23

26 year-olds was seen between 1973 and 1983, during which time the mean number of decayed, missing and filled teeth (dmft) per child halved and the percentage of children without any caries (caries free) doubled Figure 11: Reduction in dental decay amongst children in UK, Source: National Children s Dental Health Surveys 1973 to 2003 Harker R and Morris J (2005) Office for National Statistics, London In Choosing Better Oral Health, Department of Health (2005): The graph indicates the last decade to have resulted in little further reduction in dental decay There continues to be a burden of disease in small children, which is difficult to address; a small proportion of the population experiences a high proportion of the disease and children who have decayed teeth will have, on average, between 3 and 4 decayed teeth therefore most of the population s decay The same pattern is found at both regional and national levels Dental caries, like many other diseases, is increasingly associated with social deprivation x Children from socially disadvantaged groups experience disproportionately high levels of dental disease xi The 2003 National Children s Dental Health Survey found (Figure 12) that children from manual classes are more likely to experience caries than those from nonmanual classes xii Figure 12: 3 Mean Number of Teeth with Obvious Decay Experience by Socio- Economic Status of Household in the UK 2003* M a n a g e ria l a n d P r o fe s s i o n a l In t e rm e d i a t e R o u t in e a n d M a n u a l y e a r o ld s 8 y e a r o ld s 1 2 y e a r o l d s 1 5 y e a r o ld s Source (Figure 12): Office for National Statistics 2003 Children s Dental Health Survey London: ONS; 2004 Available at URL wwwstatisticsgovuk/children/dentalhealth *Hashed columns indicate primary teeth, solid columns indicate permanent teeth 24

27 Similarly, there is a correlation between the percentage of children with decay experience and deprivation; deprived groups are more likely to have decay experience This pattern is seen in both the primary and secondary teeth Locally the dental health of children in Norfolk varies around the national and regional averages as shown by the local data, regularly collected through British Association for the Study of Community Dentistry (BASCD) co-ordinated surveys In the sample of five year olds surveyed during , there was a requirement for explicit, positive consent from parents/carers of children before they could participate Of note, for the samples drawn, less than 70% took part Of the participants, around 27% of those in Norfolk had experience of dental decay; conversely 73% (nearly three quarters) were decay free This compares favourably with national levels, as shown in Table 6 It would be expected that those not participating in the survey might have higher rates of decay and less engagement with services and so the survey results are probably an underestimate of the true picture, particularly underestimating those with higher need Table 6 Dental survey results National comparison: five year olds Area 5 year old population mid 2007 Sample drawn % examined % decay free Care index* England 558, , East of England 62,935 17, Norfolk 7,023 1, Where dental decay was evident, a greater proportion was untreated than seen either regionally or nationally (*the Care Index is the proportion of teeth with caries experience which have been filled, derived by taking the number of filled teeth and dividing by the total number of decayed, missing and filled teeth) There is disagreement within the profession regarding appropriateness and benefit of filling decayed deciduous teeth and a lack of evidence based guidance on this The highest index in the country was 33% in South Gloucestershire 25

28 Table 7 Local data on 5 year olds in Norfolk The data in table 7 are further broken down to compare local authority areas in Norfolk Breckland, Broadland and North Norfolk all had a care index of below 10 It can be expected that those not decay free will have high rates of disease 5 year old population mid 2007 Sample drawn % examined % decay free Care index* England 558, , East of England 62,935 17, Breckland 1, Broadland 1, Kings Lynn and 1, West Norfolk North Norfolk Norwich South Norfolk National performance targets for dental health in young children stated that by 2003, an average of 70% of children should have no experience of dental decay This target was met across the East of England and Norfolk, but not England as a whole according to this survey which took place some years after 2003 but had a low participation rate The pattern of oral health inequalities seen at a national level is repeated locally PCT or district averages hide oral health inequalities and the fact that a small proportion of the population experiences a high proportion of dental disease The dental health inequalities mirror social deprivation Local co-ordinated dental surveys are now run as the English NHS Dental Epidemiology Programme and the results of the 2008/9 survey of twelve year olds are shown below Over a third of children have some dental decay that needs professional intervention (D3MFT) but a small proportion of this need is actually met, particularly in Great Yarmouth and North Norfolk (the care index) No data are shown for Kings Lynn and West Norfolk or for Breckland because the numbers sampled were too small 26

29 Table 8 - The Decay Experience of 12-year-old Children in Norfolk (The English NHS Dental Epidemiology Programme Survey of 12 year olds, 2008/9) PCT Name 12-yearold Population (Mid-2008) Drawn Sample % Examined Mean D 3 MFT % D 3 MFT > 0 Mean D 3 MFT (% D 3 MFT > 0) % DMFT 0 Care Index % England 608, , % % % Norfolk 8,452 1, % % % Broadland 1, % % % Great Yarmouth 1, % % % North Norfolk 1, % % % Norwich 1, % % % South Norfolk 1, % % % Figure 13 compares two earlier survey results, 5 year olds in 2003/4 and 11 year olds 2004/5, illustrating similar trends in decay experience in primary and permanent dentitions Figure 13 - The Proportion of 5 Year Olds (2003/4) and 11 Year Olds (2004/5) with No Decay Experience in Norfolk and Waveney PCTs % No Decay Yr Olds 11 Yr Olds England NS&C St HA Broadland PCT Great Yarmouth PCT North Norfolk PCT Norwich PCT Southern Norfolk PCT Waveney PCT West Norfolk PCT Source: BASCD Survey Reports 2003/4 and 2004/5 (Pitts et al, 2005 and 2006) 27

30 Cleft Lip and Palate Cleft lip and palate is a phrase used to describe a group of congenital facial malformations that occur when the upper lip and/or palatal shelves fail to fuse during embryonic development There is a range of conditions within this definition from a simple notch of the upper lip to a full bilateral cleft of the lip and hard and soft palate Successful management of patients requires multidisciplinary, highly specialised treatment from birth to early adulthood including multiple surgeries, genetic and psychological counselling, speech and language therapy, orthodontics and long-term preventive and restorative dental care xiii Orofacial clefts occur in around 1 in 500 live Caucasian births vii Clefts occur more frequently in oriental people and less frequently in those of Afro Caribbean origin The local centre for mulitidisciplinary care in the East of England is Addenbrooke s hospital, (hub), and spokes include the Norfolk and Norwich University Hospital Foundation Trust, where all of our local children are kept under regular review, co coordinating audit data with the centre, as set out in national guidance It has been observed (Norfolk OHAG, 2009) that routine dental care these children receive may not always be adequate and that there should be a greater flexibility to ensure their care in primary care is followed through Orthodontic Treatment Need The recent Children s Dental Health Survey in 2003 found that 35% of 12-year-olds in England would benefit from orthodontic treatment xiv This figure is often used to plan commissioning of orthodontic services, on the understanding that not all of these children will seek, accept or be suitable for orthodontic treatment In Norfolk there are approximately 9, year olds (Table 9, Source ONS/Norfolk County Council) and this number has reduced in recent years and is projected to reduce further over the next few years, and then increase again This indicates that current service levels, if they are meeting current demand are about right There may be changes in commissioning in neighbouring counties and knowledge of this and the potential impact needs to be understood as Norfolk providers treat children from out of county, and Norfolk children, particularly from West Norfolk, may travel to Cambridgeshire for their treatment Table 9: population projection for number of 12 year olds in Norfolk, with chart Source: ONS/Norfolk County Council Year NORFOLK , , , , , , ,638 28

31 NORFOLK 12,000 10,000 8,000 6,000 NORFOLK 4,000 2, Year Unlike most oral conditions, malocclusion does not vary between genders or social classes (although racial characteristics mean that there is some ethnic variation) Despite this, there have historically been inequalities in the receipt of orthodontic treatment vii, eg girls receive more treatment than boys and adolescents in deprived areas are more likely to have untreated malocclusion xv Local data on the prevalence of malocclusion have not been routinely collected, but the BASCD coordinated survey of 12 year olds in the academic year 2008/09 had an orthodontic need component but the results are not yet available 29

32 23 Oral Health and inequalities in Adults Dental caries The decennial National Adult Dental Health Survey, commissioned by the department of health through ONS, has shown the dental health of most people in the UK to have improved dramatically during the past 50 years This, as with the dental health of children, is attributed largely to the widespread use of fluoride toothpaste xvi During the post-war years, and when the NHS was established, the nation s oral health was poor and dental disease was rife xvii and there was little expectation that teeth would last a lifetime This expectation has now changed, with the proportion of adults with no teeth dropping from 37% in 1968 to 12% in 1998 (see Figure 14) Figure 14: The Proportion of Adults with No Natural Teeth in England, Source: National Adult Dental Health Surveys, 1968 to 1998 Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E and White D (2000) In Choosing Better Oral Health, Department of Health (2005) National surveys, conducted decennially, show that adult dental health is improving and almost a third of young adults (aged 16 to 24 years) have no fillings More adults are keeping their teeth into older age and edentulousness is expected to drop to 8% by 2008 xviii It is predicted that by 2028, around 96% of the population will have their natural teeth The proportion of younger adults who have a sound dentition (ie without any restorations or caries) has also improved dramatically, rising from 9% in 1978 to 30% in 1998 xix The average number of decayed teeth has dropped substantially from 19 teeth in 1978 to 11 teeth in 1998 xx and the proportion of younger adults, with a sound dentition (ie without any dental restorations or decay) has risen dramatically from 9% in 1978 to 30% in 1998 xxi The most recent national survey was undertaken in 2010 and a preliminary report is expected this autumn, with the final report in 2011 The independent review of NHS dental services in England (Steele, 2009) uses trends from successive adult national dental surveys to illustrate the heavy metal wave (Figure 15) where the younger adult generation of 1978 had high levels of decay and many fillings, and by 1998, they were in middle age and still exhibited the highest treatment need and rates 30

33 Figure 15: The heavy metal wave (Steele, 2009) Populations with high proportions of older people in the future will require significant resource to maintain past restorations It could be projected from the figure below that by 2008, the cohort with the highest treatment need had reached the 55 to 64 age group and so over the next ten years, these people will be included in the population group 65 years and over While oral health has improved generally, it is not all good news Population averages hide oral health inequalities, as seen in Figure 15 This highlights that the prevalence of oral disease is highest in areas of social deprivation Figure 16: Proportion of Adults with Decayed/Unsound Teeth or Periodontal (Gum) Disease by Social Class Percentage I, II, IIINM IIIM IV, V Social Class of Head of Household 47 Decayed/Unsound Teeth Periodontal Disease Source: Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E, White D Adult Dental Health Survey Oral Health in the United Kingdom 1998 Adults from the most deprived areas are more likely to have one or more decayed or unsound teeth than those from less deprived areas, as seen in Figure 15 31

34 Figure 17: Teeth Condition Among Dentate Adults in England by Jarman Area Source: Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E, White D Adult Dental Health Survey Oral Health in the United Kingdom 1998 Available at URL: Attendance for Treatment Despite the higher level of need in adults from deprived areas, it is adults from the least deprived areas that are more likely to have restored teeth This suggests that those from higher socio-economic groups are more likely to seek dental treatment Similarly, individuals from socially deprived groups report that they are more likely to attend irregularly and only when they have a problem (see Figure 17) Figure 16 shows that much decay goes untreated (even in the least deprived socio-economic groups the proportion of untreated decay is as high as 50%) Figure 18: Reported Usual Reason for Dental Attendance of Dentate Adults by Social Class 100 Percentage Regular check-up Occasional check up Only with trouble II, II, IIINM IIIM IV, V USUAL REASON FOR DENTAL ATTENDANCE Source: Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E, White D Adult Dental Health Survey Oral Health in the United Kingdom 1998 The Steele Review has explored in depth why people can be reluctant to go for routine checkups and care Reasons are common, many and complex often tracing back to fear, fear of cost, inconvenience, perceived difficulty in finding a trusted service (especially as people move home and job) and a misalignment of professional and public concepts of the purpose of NHS care, that includes preventive advice There is little direction for patients and increasing demand for aesthetic work 32

35 Local data on adult oral health are not routinely collected in the UK In many areas there is a paucity of local information on adult oral health so measures of child dental health are the most commonly used indicators of dental disease The decennial national surveys do, however, collect data to regional level The findings of the most recent adult survey (1998) suggests that oral health inequalities are geographically clustered; as Figure 19 shows, adults in the South of England tend to have better oral health than adults in the North Figure 19: Dental Status of Adults in England by Region Percentage % Natural Teeth Only Natural Teeth with Dentures Edentate Northern & Yorkshire Trent Eastern London South East South West West Midlands North West Source: Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E, White D Adult Dental Health Survey Oral Health in the United Kingdom 1998 Gum (Periodontal) Disease in Adults It is difficult to collect robust data on periodontal disease; however, national surveys suggest that the incidence of severe periodontal disease is declining xxi Nevertheless, chronic periodontitis still affects a significant proportion of the population The most recent Adult Dental Health Survey, in 1998, found that 54% experience chronic periodontitis Prevalence increases with age as 14% of year olds and 85% of people aged 85 years and over have signs of the disease Approximately 5% of the population suffer from severe disease xxii and are, therefore, at significant risk of tooth loss Periodontal disease is exacerbated by poorly or unmanaged diabetes Findings of national surveys suggest that the pattern of oral health inequalities in gum disease mirrors that of dental decay; adults who have the most severe disease tend to come from the more socio-economically deprived groups Figure 16 shows that groups with the highest need, both in terms of dental decay and periodontal (gum) disease, come from the most deprived socio-economic classes Oral Cancer in Adults The prevalence of oral cancer had been declining steadily over the past few decades, but it has recently begun to rise xxiii In 2001, national survey data estimated that there were 4400 new cases in the UK, making up 2% of all cancers In 2003, approximately 1,600 deaths were attributed to oral cancer While mouth cancers account for only around 1% of all new UK cancers per year, the incidence is rising 33

36 and now accounts for approximately 800 deaths annually The five-year survival rate in England is around 50% if the patient presents at an advanced stage However, early detection improves five-year survival rates dramatically, to just below 90% xxiv Unfortunately, the low awareness of oral cancer among the public, and the painless nature of oral cancer in its early stages, mean that early presentation is rare People tend to only seek treatment when the cancer is more advanced and difficult to treat Incidence of oral cancer increases with age from 30 years, although prevalence is beginning to increase in younger adults xxv It is twice as common in men as in women, however, the gender difference is becoming less pronounced over time There are wide geographic variations in prevalence and those in lower socioeconomic groups are more susceptible xxvi Between 2004 and 2008, the annual average for the East of England was 808 cases, of which 414 are from the Anglia Cancer Network that includes Norfolk residents (Source: Cancer Registry) 34

37 Summary points Section 2 Oral disorders and epidemiology Dental decay, periodontal disease and almost all oral cancers are completely preventable but when they occur have life long effects requiring continued professional input Hence, there is good justification to invest in oral health promotion and prevention as evidenced in Choosing Better Oral Health Many risks for oral disease are the same as those causing other disease and hence many aspects of oral health promotion can be dealt with through established wider health promotion services and initiatives in Norfolk eg Health Trainers, Change for Life, workplace health if the links are made; prevention messages should be consistent Malocclusions are usually natural variations in the population with about 35% children above the threshold where treatment might be warranted on the NHS using current policy Numbers of 12 year olds are falling slightly hence it is expected that no increase in orthodontic capacity needed Dental health of children has improved enormously since the 1970s with well over half with no decay Higher disease levels are increasingly concentrated in lower income groups but are still seen across society It is important that local survey work is explicitly commissioned The most recent dental survey results presented a rosy picture of child oral health but because of national policy, children could only participate if their carer gave consent The care index has shown that amongst children surveyed, much disease is not treated but this is not unique to Norfolk It would be useful if similar consent policy was used as it is with the height and weight measurement programme, ie opt out rather than opt in The current dental contract is designed to give dentists enough time to use preventive techniques Commissioners can recognise the benefits of supporting ongoing development for dental health professionals do this effectively Children with cleft lip and palate deserve the highest standards of general dental care Among adults, numbers with no teeth at all are very low and confined mainly to the oldest members of society Most people now should expect to retain their teeth for life; older adults have restored dentitions that require careful maintenance; there should be good access to specialised advice and care Many young adults have no fillings at all Disease patterns reflect economic deprivation There is evidence that higher socio economic groups are more likely to seek dental treatment and that people who go only when they have a problem are more likely to be from a more vulnerable background Increased focus on patient views will be valuable for future commissioning of dental services but currently we must ensure that appropriate information on services is available To enable access of services to all, it is really important that local dentists agree with each patient a recall interval appropriate to their risk of needing professional input NICE guidelines are very clear on what is required and how it is done NHS Norfolk needs to work collaboratively with the profession locally to ensure this takes place 35

38 Section 3: Factors affecting Oral disease and approaches to prevention 31 Biological and social determinants The factors underlying the development of poor oral health are well known to the public and the underlying science is well researched and understood The main biological risk factors are: Poor diet and nutrition: High consumption of free sugars leads to dental caries Poor nutrition can increase risk of oral cancer Poor oral hygiene: Poor plaque control will increase risk of dental caries and gum disease Lack of exposure to fluoride: Regular exposure to fluoride has a protective, anti-caries effect Tobacco and alcohol: Smoking increases the severity of gum disease and is one of the main risk factors for mouth cancer Smoking combined with excessive alcohol consumption leads to a much greater risk of cancer than either in isolation Injury: Injury to teeth can occur through accidental injury or violence or contact sports Social approaches (Figure 20) can reduce risks across a whole population Policy that makes it easier for everyone to have good diet, exposure to fluoride and good oral hygiene will have a relatively greater benefit for vulnerable population groups, as long as the policy takes account of their needs Key vulnerable groups and how their differing needs require a more tailored approach are described later in this section Policy on food and nutrition already recognises dental health issues For example breast feeding is promoted; breast milk does not cause dental decay However, fluoride, both in water supplies and through brushing with fluoridated toothpaste, protects against tooth decay but there is controversy about adding fluoride to public water supplies Norfolk does not have its drinking water fluoridated and as it is harder to assure use of toothpaste amongst vulnerable population groups, targeted promotion of use of fluoride toothpaste can be commissioned, for example through Sure Starts, for young children All policies to reduce smoking and alcohol use will improve population oral health Health and safety policy, plus accident reduction policies, such as compulsory seatbelt use, safe play areas and use of mouth guards for contact sports reduce risk of injuries to teeth Supporting individual lifestyle choices (eg, for dental health, choosing food/drink low in free sugar, and infrequent snacks), should be encouraged where there are existing opportunities, eg patients seen regularly because they are on a GP risk register, or those in contact with Health Trainers For the population that attends a dentist, an individualised discussion can take place at the chairside 36

39 Figure 20: The Underlying Causes of Oral Health Source: Modified from Watt, 2005 in Department of Health Choosing Better Oral Health An Oral Health Plan for England 2005 Available at URL: e/dh_ Using the Common Risk Factor Approach to tackle inequality Tackling the risk factors of oral diseases and promoting oral health, with appropriate targeting for vulnerable groups will reduce population oral health inequalities It is important to acknowledge that the provision of high quality dental services is only one aspect of this as dental services are, by necessity, treatment focused and will not eliminate oral disease or health inequalities alone, no matter how accessible or effective they may be The most powerful promotion of oral health is through collaboration, where possible, of oral health promotion with generic health promotion, as described in Choosing Better Oral Health (Section 4) The Common Risk Factor Approach emphasises the need to tackle the common risk factors and conditions that are shared by common chronic non-communicable diseases xxvii As illustrated in Figure 21 The common population health risks that include a major dental risk are poor diet, smoking, stress, high alcohol consumption, poor hygiene and injuries Targeting the reduction of these risk factors at a population level (as is happening in NHS Norfolk) as well as to key groups would simultaneously reduce the incidence of obesity, health disease, stroke, cancers, diabetes and mental illness, in addition to oral diseases If the Common Risk Factor Approach is broadly adopted, it has the added advantage that all health professionals will communicate consistent health messages to the public Strategic approaches to improving oral health will therefore be linked to other, more general, health promotion initiatives 37

40 Figure 21: The risks, common between oral and other chronic diseases Source: Sheiham and Watt, 2000 in Department of Health Choosing Better Oral Health An Oral Health Plan for England 2005 Available at URL: e/dh_ The evidence base for dental service advice and care on prevention is published in Delivering Better Oral Health (2009); every dentist in England has been sent a copy, directly from the Department of Health Within dental services, dental health promotion is delivered through the main dental contract, by dental healthcare professionals to individuals who access it In addition, the salaried services have a dedicated health promotion service that liaises with other professional groups such as teachers, Sure Start staff and health visitors and now stop smoking services, health trainers and other public health services This service can also work one to one with patients treated by salaried service staff, who are as such from vulnerable groups Other examples of health protection work includes: Diet: Advice on healthy eating for dental health is aligned with government policy on general healthy eating advice All teams giving healthy eating messages are likely to be giving the right message for oral health, but there is a role to always check for this Advice specific to oral health, and evidence for this, is in Choosing Better Oral Health s 38

41 Overweight and Obesity Any association between dental caries and obesity has limited supporting evidence at this time xxviii However, part of obesity prevention is dietary advice A person is described as overweight or obese if their body mass index (BMI) exceeds certain levels BMI takes account of both weight and height The Norfolk Health Profiles highlight 1:4 1:5 adults in Norfolk being obese xxix which is very slightly lower than the England average The National Child Measurement Programme figures for NHS Norfolk in 08/09 showed 91% of children at Reception year age and 18% in year 6 to be obese And local analysis has estimated one in 3 or 55,000 children (0-15yrs) who are overweight or obese Figure 22 shows the distribution of childhood overweight and obesity, charted from the 2008 National Child Measurement Programme Areas with the darkest shading are the highest fifth in terms of prevalence of these conditions Many are in rural areas, particularly in West and North Norfolk, where services such as schools and libraries are sparse, the problem seems to be more widespread It is likely that diet along with a lack of active travel opportunity is a significant factor in this Figure 22: Year R and Year 6 % overweight and obese in Norfolk (source: National childhood Measurement Programme) Policies across government are increasingly focussed on stemming the rise of obesity, using the common risk factor approach and NHS Norfolk is fully engaged in this, eg through the Change 4 Life Programme Targets in NHS Norfolk s Strategic Plan, Bold and Ambitious, aim by 2014 to achieve a 2% reduction in the number of obese primary school, and a 4% reduction in the number of obese year 6 children Salaried dental service health promotion teams have a role to ensure that advice 39

42 given to the public is consistent, and do not compromise the dental health message but can support local initiatives to improve oral health There is a small but increasing number of people with morbid obesity (numbers are not known), which severely compromises medical and physical health, such that providing dental treatment, and indeed other healthcare, can become problematic For example, the person presents as a higher risk if they need sedation or a general anaesthetic, or domiciliary care might be required Individuals should be assessed and treated on an individual basis, dependant on need Smoking The estimated proportion of adults who smoke in Norfolk is 227%, not significantly different from the England average of 222% (Source: Norfolk County Health Profile, 2010) However, the East of England Lifestyle Survey 2008 estimated smoking prevalence to be only 189%, similar to a regional average of 184% Smoking or chewing tobacco can affect oral health in a number of significant ways These include increased risk of oral cancers and pre-cancers, increased severity of gum disease, premature tooth loss and poor wound healing It is difficult to demonstrate this at a local level due to the long term impacts Oral Cancer figures for the Eastern Region are over 800 per year, of which 414 are dealt with through the Anglia Cancer Network It would be useful to track future incidence of this catastrophic disease as smoking rates fall In 2009/10, Norfolk Stop Smoking Service achieved week quits, 30% of which were in the 20% most deprived areas (MSOAs) In May 2007, the Department of Health published Smokefree and Smiling: helping dental patients to quit tobacco as part of their ongoing campaign to involve dental teams in supporting people to stop using tobacco xxx The local stop smoking service has linked with dental practices and is working closely with them and this work should be recognised and encouraged Alcohol The Norfolk Health Profile reports rates of binge drinking, which applies usually to young adults xx There is increasing concern over excessive alcohol use by older age groups A report from ERPHO in 2008 on Mental Health in Norfolk identified alcohol related inpatient admissions in 2005 There is a well-recognised relationship between alcohol misuse and oral disease Research suggests that patients suffering from alcohol use disorders experience poor oral health (including significant levels of dental caries, gingival inflammation, soft tissue abnormalities, tooth erosion and an increased risk of developing periodontal disease) xxxi Excessive alcohol use is also a significant risk factor for oral cancer Of particular concern is the synergistic action of excessive alcohol consumption with tobacco (smoked and chewed), which when used together, will substantially increase the risk of developing oral cancer xxxii Drug Abuse Intravenous drug use is associated with poor oral health, in particular dental decay and periodontal disease This is thought to be due to a complex relationship between a number of factors, which include poverty, self-neglect, consumption of high sugar foodstuffs, poor oral hygiene and the intake of methadone syrup xxxiii,xxxiv Prolonged drug use is often associated with self-neglect and a cariogenic (decay 40

43 promoting) diet xxxv There are indications that drug addicts experience severe dental and periodontal tissue destruction xxxvi In comparison with the general population, drug users tend to have poorer oral health and display lower utilisation of dental services xxxvii Not everyone is known to the dental services; those who are frequently have the severest problems and are defined as problematic Many chaotic drug misusers are homeless and have a history of offending, making the organisation of their care very difficult There are just over 1000 people currently registered for intense support and these people have the severest problems They complain of dental pain that can sometimes cause them to relapse from abstinence Furthermore, they may have blood borne disease and hence fear stigmatisation if they present for treatment to the dental services In Norfolk there were 2,991,15 to 64 year olds who were problem drug users (source ERPHO, 2008) Data from the National Treatment Agency confirm that this is fewer than the England average population rate which is (99/1000), this group has special dental needs and require greater access to dental care than most The barriers they face are common to many, but relatively greater; in the knowledge their dental health may be poor and neglected, they can feel that they will be stigmatised by dental staff Many fear pain, needles, and costs Those otherwise rehabilitated and ready to develop their lives can find particular frustration in obtaining appropriate sympathetic care for their high treatment need It is important that services can liaise with treatment/offender services to help the most chaotic people, and that access to services across the county is simple 33 Populations in special situations It is clear that despite substantial improvements in oral health, marked inequalities remain, with socially deprived and/or vulnerable groups in society with poorer oral health and poorer access to oral health care services, although they may be exempt from paying dental charges Groups of people particularly at risk from oral diseases include the following: People living in areas of material and social deprivation Norfolk has some significant sectors of the population with income deprivation (Figure 8) Several public health programmes in Norfolk target these groups by geographical area, eg Joy of Food, Sure Starts, health trainer services (that link into people in the fifth quintile, who are identified in the newly established Health Checks, a GP commissioned service) People identified by the health checks receive lifestyle/behaviour change advice They may have a history of non attendance at a dentist and a high unmet oral health need Community workers usually have a good knowledge of oral health risks, but they report a lack of resources such as information on the subject tailored for their group, and knowledge on where to direct people for appropriate and sympathetic healthcare The dental contract has been unable to incentivise all but the most dedicated dentists to prioritise high need groups, where individuals may require a lot of time and skill, and may miss appointments The success of the Siskin centre and the access service in Kings Lynn in providing services for these groups is acknowledged and valued by those providing the targeted support to vulnerable groups However, such services are lacking in Thetford, so patients have to travel to access these centres Oral health begins at birth, and it is important to promote uptake of breastfeeding alongside healthy eating particularly for these groups as breast milk does not cause dental decay where as the effects of sweetened bottled drinks once teeth erupt, are devastating 41

44 The salaried dental service formerly targeted schools for dental inspections where a high percentage of children received free school meals Information on what is provided locally is in the service delivery section of this report, collected through service monitoring information Looked after children At any one time there are just over 900 children looked after in Norfolk, ie where a local authority is the corporate parent It is particularly important that dental care needs are not overlooked for this vulnerable group The Children and Families Programme Board has been contacted by NHS Norfolk and the overseeing manager has confirmed that that oral health is a topic of annual discussion for each child and that regionally, the use of fluoride varnish for this group is being promoted It is recommended that this is supported in Norfolk through enabling training, and particularly encouraging salaried services to make this service available and to target it according to the guidance in Delivering Better Oral Health People who have learning disability Individuals with disabilities experience more oral disease and have fewer teeth than the general population They also have greater unmet dental needs xxxviii as they have more difficulty in accessing dental care xxxix Access to oral health care is affected by where people with learning disabilities live Evidence suggests that adults with learning disabilities living in the community have greater unmet oral health needs than their residential counterparts and are less likely to have regular contact with dental services xl A detailed assessment of general health need in Norfolk has been commissioned and is due for completion later this year and most medical practices either have a register, or have arrangements with a neighbouring practice, of their patient s with learning disabilities known to health services Registrants have an annual health review which includes recommendations for accessing regular dental care This is in line with guidance: Valuing People Now (Department of Health) Many of these people with the severest problems already have good dental care and the Salaried services are mentioned by special needs services providers as being very good, particularly those at the NNUH, North Walsham, the Siskin Centre and at Kings Lynn Staff have demonstrated appropriate understanding and skills Part of mainstreaming patients with learning difficulties, however, is to ensure that all services commissioned, where possible can provide proportionate care This promotes better diversity of choice for the patient, freeing up the most specialised aspects for only those with severest need Salaried/specialised services in this field should work proactively with generalist dental practices to promote dental pathways appropriate for the individual and to enable patients to seek at least their routine dental care as close to home as possible There are many more people with less severe learning difficulty, and this group might not be recognised by health services as such, and these people can misunderstand messages, including appointment arrangements, and find it difficult to act on preventive advice It is wrong to generalise, however, these people are more likely to live in areas of deprivation, and access care only when they feel they need it, and for example when they have a dental problem It is crucial that access is maintained sensitive to the needs of this unquantifiable group Work is being undertaken through the learning difficulty needs assessment to predict numbers with mild learning difficulty by using predictions from numbers of statemented children in schools This data is not yet available for NHS Norfolk 42

45 People with mental illness The Eastern Region Public Health Observatory, ERPHO (2008) published indicator data on mental health in the general population of NHS Norfolk There were: 11,360 claimants of incapacity benefits due to mental health conditions in admissions for schizophrenia in 2005/6 2, to 64 year olds who were problem drug users 11, 255 alcohol related inpatient admissions in ,172 people on enhanced or standard care programmes Of 11,248 people aged 18 to 61 2,661 were on either standard or enhanced care programmes Recent national policy has recognised gaps in services for people with Autism and Aspergers Syndrome These people are at risk of finding dental care unacceptable and dental teams may be poorly equipped to help them The Salaried services have staff that understand the needs of this group and should be available if difficulties are encountered at general practices, and the situation monitored through patient feedback The ERPHO report emphasised the evidence that employment is beneficial to mental health and that people who have been abused, been victims of domestic violence or who have drug or alcohol problems are more likely to suffer mental health problems There are higher rates of mental health problems within black and minority ethnic groups and high rates in prison populations Between a quarter and a half of all homeless people have a serious mental disorder and are alcohol dependent Frail Elderly Older people have specific oral health needs as oral health problems increase with age In particular, age related changes can lead to xerostomia (often drug related), root caries, recurrent decay and decreased manual dexterity can lead to reduced plaque control Systemic problems can also have an effect on oral health, for example, many older people suffer from progressive neurocognitive impairing illnesses (eg Parkinson s disease and Alzheimer s disease) which will cause difficulties in controlling and retaining dentures xli In older people, the retention of natural teeth into old age makes a major positive contribution to the maintenance of good oral health related quality of life and there is a clear and consistent relationship between retention of natural teeth and a healthy diet and good nutrition xlii Dental care for frailer older people may require extra skill and take longer than for other people Some live in residential settings (see below) but a good many live in the community (see Figure 6) and so a wide range of service options need to be available to them People in long term institutional care (including residential homes, psychiatric hospitals, prisons) a) Residential homes In terms of end of life residential care, the Care Quality Commission regulates residential care homes In 2009/10 there were approximately 387 homes registered in Norfolk, of which 110 had capacity for dementia patients and 67 offered nursing care The total capacity was 9,388 places (source: NHS Norfolk) 43

46 These are mapped on Figure 23 and are widely distributed across urban and rural settings More remote settings may experience staffing difficulties and retaining trained staff Figure 23: map of residential and care homes: Source NHSN 2010 An indication of the number of social services funded places across these homes is shown on table 10 Numbers related to those aged 65+ in Residential and Nursing Care on 30/06/2010: Table 10: places commissioned by Norfolk Social Services for people aged 65+in residential and Nursing Care on 30/06/2010 Care type Number Residential 3,083 Nursing 535 Total 3,618 The remaining places are self funded, but may be commissioned from neighbouring authorities, in which case NHS Norfolk remains responsible for commissioning suitable dental services It is expected that residents in institutions have access to dental care; the first choice is that they make an outing to visit a surgery, where care provision is optimal Expecting a domiciliary visit is a last resort as the range of care that can be provided is limited It is also not a cost effective way of providing a service Where domiciliary care is required, and this equally affects housebound people as well as those in institutions, there should be a choice of provider In Norfolk there is a contract with a PDS provider, plus services from the salaried service It is unclear how patients access either, other than by knowledge of the services or referral from a doctor or dentist It is likely that some sectors of this population will be unaware of the options open for their residents It is important that care home managers are aware of oral health and healthcare issues and information/advice needs to be targeted to this group, and local training available for care workers 44

47 b) Psychiatric care The Mental Health National Minimum Data Set for 2008/9 records for Norfolk that 11,258 people used mental health services for adults or older people and of these, 1,314 patients were detained Length of stay can be protracted and the average daily bed occupancy was 312 These patients need access to dental care, and currently this is provided by the salaried dental service The service also provides care for residents of the medium secure unit at Thorpe St Andrew c) Prison populations The standard of oral health in prison populations is significantly worse that of the general population xliii Norfolk has three prisons with the following numbers: Table 11: Prisons in Norfolk and occupancy, 2010 (Source: Prison Commissionner, NHS Norfolk) Prison Prisoner number Norwich 767 Bure* 520* Wayland 1,017 Total 2,304 *Possibly an extra 100 next year, bringing the total in Norfolk to 2,404 Turnover of inmates and mobility between prisons complicates health care management Prison is an opportunity to offer access to care for disadvantaged groups who would normally be hard to reach Not only should effort be made to improve the health of the individual but also to influence the health and wellbeing of prisoners' families and the wider community Prisoners tend to have more decayed teeth, fewer filled teeth and less natural teeth than the general population, even when social class is taken into account (adults in social classes IV and V have been shown to have fewer decayed or unsound teeth than the prison population) xliv Evidence suggests that there is a substantial amount of unmet need in British prisons xlv Summary data show prison dental health to be four times worse than the average population Prison dental services now operate to a new contract, with quality markers The service is staffed by people from the salaried dental service Services are developing in a way integrated to overall healthcare of prisoners, using a triage system to prioritise those in greatest need Needs are confirmed by the service providers to be high There is a need for better targeted information for health trainers and the probation services to use when working on prevention Homeless people Homeless people tend to have poorer health than the rest of the population Often concentrated in city centres, where hostels are located, this group of people often have high proportions of people with history of mental illness, substance misuse and previous prison sentence However, this is far from the whole picture as some people remain unknown to authorities, staying with friends or frequently moving Data on the oral health status of homeless individuals is limited; however studies consistently report a high clinical and perceived need for oral health care within this population xlvi They have a higher dmft (decayed, missing and filled teeth) than the 45

48 general population and there is a greater prevalence of dental pain and periodontal (gum) disease xlvii Homeless people tend to have fewer remaining teeth and heavy plaque accumulation xlviii Despite these high levels of need however, homeless people experience difficulty in accessing dental services xlix Health services targeted to this group include City Reach This service has good links with the salaried dental service and engages with any NHS practice convenient for their client City Reach is working with about 450 clients at any one time, with a turn over of 40 to 50 people per month A problem highlighted is that these people are unlikely to be registered with authorities and hence cannot claim exemption from dental charges Ethnic groups with evidence of social disadvantage Data on the oral health of ethnic groups are not routinely collected in the UK therefore a comparison of their oral health status is limited Reasons why oral health may be at increased risk include lack of access, knowledge of or communication with care or advice and cultural issues It is important to consider the cultural characteristics of each subgroup particularly when designing oral health promotion activities for diverse ethnic groups Data in section 1 (Fig 7a and 7b) show the comparatively smaller proportions of these groups in the Norfolk population, which increases the risk of them being overlooked Migrant workers Substantial communities of migrant workers within Norfolk are known to be in Thetford and Kings Lynn, where health trainer services help link families to mainstream services, often the first port of call being the salaried dental services The Health Trainer service has suggested that commissioners can promote collaboration between family dental services and salaried dental services through commissioning information, and also by ensuring services that these people may prefer, that might include drop in and out of hours sessions and time to explain how NHS dental services and their charges operate There are many more migrant workers, dispersed, often working in the private sector; employers can be reached through business partnerships such as the Local Strategic Partnerships at District and County level and individual families may access other health care services, such as A&E or through registration with a GP Asylum seekers Clearsprings has 150 beds for asylum seekers, as part of trans UK arrangements All clients are offered medical appointments and the dental practices involved have good links with local interpreter services Travelling community There is very little published literature on the oral health of Travellers While there are no robust data on the prevalence of oral disease in this population, it seems reasonable to assume that disease levels will be relatively high, as this is a socially deprived group A small study in East Hertfordshire in the early 1990s found that 70% of traveller children had dental caries l The group made little use of preventive services with the majority of travellers neglecting to visit a dentist regularly Those who do are more likely to be settled and literate Travellers report going to the dentist mainly when they are in pain l Healthcare services for the travelling community in Norfolk have been a focus for development in recent years and it is important that dental services continue to be 46

49 supported in their involvement Services report a high level of dental care need Arrangements have been more successful at official sites, but there are more problems for people who use unofficial sites Summary Points Section 3 Biological and social determinants of oral health Biological determinants of oral health are diet, oral hygiene, reducing tobacco and alcohol and reducing risk of injury Fluoride protects teeth against decay Particularly vulnerable people, such as drug misusers or people with mild learning disabilities, live across the county, often, but not always, concentrated in areas of greatest deprivation Services need to be appropriate (eg drop in as well as mainstream) and accessible Social approaches through policy and cultural change, such as encouraging healthy food choices and smoke free places will protect and maintain population oral health There are major initiatives in Norfolk to tackle obesity, smoking, alcohol and drug misuse Dental public health needs to link to these Water fluoridation, which would reduce dental decay, does not have public support but a lot can be done to support individual lifestyle choices, eg use of fluoridated toothpaste, that reduce an individual s risk of oral disease Populations in special situations People living in areas of material and social deprivation Geographical areas with the greatest socioeconomic deprivation already have targeted health improvement initiatives Dental services need to be proactive to meet needs identified This is currently most evident with salaried services NHNN needs to ensure oral health messages are consistent and that there are adequate drop in and urgent services along with capacity to complete extensive courses of treatment Leaflets and information appropriate for specific client groups, produced locally would be helpful Current arrangements for school dental inspections should be reviewed in the light of potential outcomes Targeted fluoride varnish schemes for children, especially those with special needs, should be considered, including through liaison with social services Looked after children: Links have been made with the manager of the service; oral health issues are part of a regular review for each child Links should be maintained with this service, possibly through the health promotion team in the provider arm 47

50 Learning Disability Good liaison with local dental services is required, especially in planning appointments People with severe LD can have a carer to accompany them and their knowledge and understanding of both personal and professional dental care services is important NHSN should aim for good access to services around the whole county, both for continuing care and for drop in style services for those who prefer treatment only when there is a problem Better information should be available on this complex group by the end of 2010 through the JSNA, on completion of a project Mental illness It is important that good mental health is promoted across society, and that, by services are patient focussed, people with mental illness are recognised and treated with respect and dignity Special issues might include failure to attend for care, phobias and dental neglect Frail elderly These people live across the county and may take longer to see and treat than, for example, a young adult Domiciliary care might be appropriate, but only where the full benefits of a clinical setting are truly inaccessible to the person Long term institutional care There are almost older people receiving institutional care in homes across Norfolk It is important to work with home managers to develop and promote guidance that is backed up by appropriately tailored services Just over 1,000 people are detained with mental health problems per year If these are long stay, then dental services must be as available to them as the rest of the population The prison population is over 2,000 and their dental services must be as available as they are to the rest of the population For the offender population that is frequently in and out of prison, there should be continuity of care where possible, and this can be achieved by dental service providers working proactively with offender services Homeless People There is no definitive data on numbers of homeless people, but services such as City Reach cater for a proportion about 450 per month that includes a turn over of 40 to 50 48

51 Dental services need to be flexible to meet the individual needs of clients who will find it difficult to keep appointments and are likely to have dental health much poorer than the average person eg drop in style services A key barrier to services is that exemption from dental charges cannot be demonstrated Ethnic groups with social disadvantage These are likely to be clustered where there is other disadvantage and hence may be targeted with other health promotion initiatives It is important that approaches and information are culturally sensitive Migrant Workers Collaboration with health trainers working with these groups would be helpful Culturally sensitive local information on services would be useful, along with good drop in and out of hours care, with information and guidance to encourage uptake of mainstream dental services 49

52 Section 4: Prevention Services 41 Water fluoridation Adding fluoride to water supplies has a demonstrable long term benefit to population dental health, with no adverse effects Populations in the North East and Birmingham have benefitted for many years Water fluoridation is defined as the controlled adjustment of a fluoride compound to a public water supply in order to bring the fluoridation concentration up to a level which effectively prevents caries xxi The optimal concentration in temperate climates is 1 part per million (ppm) Approximately 10% of the UK population (6 million people) are currently receiving water with a fluoride content adjusted to the optimal level (including naturally and artificially fluoridated areas) The water supply to Norfolk is not artificially fluoridated and the naturally occurring levels were last analysed by Norfolk PCTs in 2003 li (Table 12) Local Authority Area Breckland Broadland North Norfolk Norwich South Norfolk Table 12 Natural Water Fluoride Levels in Norfolk Parishes 2003 Low Fluoride (<03ppm) Attleborough, Beetley, Dereham South, Swaffham, Thetford North, Weeting Aylsham, Foulsham, Hellesdon, Hoveton, Lyng, Mancroft, Plumstead, Sprowston Aylsham, Beetley, Cromer, Fakenham, Hoveton, Martham, Mundesley, North Walsham, Sheringham, Wells Bowthorpe, Heigham, Sprowston, Lakenham, Mancroft, Plumstead Heathersett, Kirby Cane, Lakenham, Poringland, Wymondham Intermediate Fluoride (03-07ppm) Dereham North,Reepham Happisburgh, Holt, Stalham Brundall East Harling, Harleston, Long Stratton, Mattishall Docking, Downham Market, Feltwell, Grimston, Hunstanton, King's Lynn, West Leziate, Marham, Middleton, Norfolk Sandringham, Snettisham, Swaffham, Wisbech Source: Data supplied by Anglian Water and Essex and Suffolk Water, reported in Murphy, 2003 (Data for 1992 shows similar fluoride levels, suggesting the change since 2003 may have been minimal) The best available evidence suggests that the fluoridation of drinking water reduces the prevalence of caries, both in terms of the proportion of children who are caries free and by the mean change in dmft There is also evidence to suggest that water fluoridation reduces the severity of caries (as measured by dmft) across social groups and between geographical locations lii Research has shown that socially deprived areas benefit more from fluoridation liii Water fluoridation is consequently one of the few public health interventions that directly reduce health inequalities Following a local oral health needs assessment PCTs may elect to fluoridate their water supply in order to reduce oral health inequalities Until recently, water 50

53 companies have had the right to refuse to fluoridate, which has limited the number of people in the UK receiving fluoridated water This changed with the Water Act 2003, which gave Strategic Health Authorities (SHAs) the authority to make this decision, following a public consultation Public opinion has made such decisions very controversial as seen when South Central SHA decided to fluoridate Southampton and surrounding areas two years ago The outcome of a judicial review is still awaited In the recently published best practice guidance on Fluoridation of Drinking Water, the Department of Health states that water fluoridation schemes would ideally serve precisely only the high-need target population where the prevalence of disease is high, although it is likely that any scheme will also serve some areas with low decay levels A further consideration is that any feasible scheme may cross PCT and SHA boundaries necessitating a joint consultation process 42 School dental inspections The Functions of Primary Care Trusts (Dental Public Health) (England) Regulations 2006 specify that a Primary Care Trust must provide or secure provision of the following, that it considers necessary to meet all reasonable requirements within its area for dental inspection for pupils in attendance at schools maintained by local education authorities These services are commissioned by Norfolk Community Health and Care, but at a minimal level such that only special schools are covered The new government lists child health as a priority and it is anticipated that greater interest will be shown in school dental inspections as a way to increasing access to services for those in socioeconomically deprived areas Schools have historically been selected where there are a high percentage of children eligible for free school meals The report on current dental activity will provide information on the extent of school dental inspections carried out by the salaried service in Norfolk 43 Dental Check ups Dental check ups are listed in the Marmot Review as a preventive service These are costed at over 900K per year across England and are the biggest single contributor, possibly more costly than immunisation programmes Each dentist has an evidence based tool to deliver preventive services (Delivering Better Oral Health, 2009) that covers assessing disease risk and recommended preventive interventions for different population groups Correctly applying the NICE guidance on recall interval between dental check ups will ensure that this valuable resource is targeted more appropriately so that those regular attendees with low treatment need are seen relatively less often, and hence there will be capacity to provide more services to people who have not regularly used services before and are likely to have a higher treatment need Service data on access shows how many different people have passed through primary dental care services in a two year interval, which is a time interval within which most people would be expected to attend to receive routine maintenance, care and advice In Norfolk about 58% of the population have attended an NHS dentist, and a further unquantified sector will pay for care privately 51

54 Early stages of dental disease are symptomless and a professional dental inspection can detect things going wrong at an early stage, resulting in a less damaging long term effect and less costly interventions 44 Oral health promotion As described in Section 3, to improve and standardise preventive advice in the clinical setting, the Department of Health has sent to each dentist in England a manual, Delivering Better Oral Health (updated 2009) which guides the dentist through assessing disease risk for each patient and then assigning evidence-based advice and actions There is evidence that regular professional application of fluoride varnish, outside the surgery setting, has a preventative effect This has been taken forward in some parts of England through commissioning trained staff to provide a service from supermarkets in school holidays It could equally be offered at Sure Starts (for children) The national oral health strategy is Choosing Better Oral Health: an Oral Health Plan for England Choosing Better Oral Health provides a good practice framework for tackling oral health inequalities For example to reduce oral health inequalities in young children the focus is on two main areas - diet and nutrition and oral hygiene (see Figure 23) In line with the Common Risk Approach, oral health promotion is incorporated into generic health promotion where possible; to ensure that consistent health messages are given To this end, promotion of oral health in children requires partnership working from the following stakeholders: Dental teams Public Health specialists Oral Health Promotion Team Health visitors Health improvement specialists Sure start and children s centres Healthy schools programmes Local authorities Voluntary groups 52

55 Figure 24: Oral Health Promotion Activities Aimed at Reducing Oral Health Inequalities in Young Children TOPIC FOCUS GOOD PRACTICE INFANT FEEDING Promote breastfeeding Coma recommendations Oral Health input into local infant feeding strategies and guidelines POLICY Promote the development and adoption of nutrition and healthy eating guidelines GUIDELINES SUGAR CONTENT Discourage addition of sugars to weaning foods/drinks and vitamin supplements Encourage reduction in sugar content of soft drinks/breakfast cereals, confectionary, etc Encourage caterers to reduce sugars in prepared foods Encourage vending machine providers to include sugar-free choices DIET AND NUTRITION ORAL HYGIENE PUBLIC INFORMATION AND SUPPORT EARLY TOOTHBRUSHING BODY AND ORAL HYGIENE TRAINING AND SUPPORT Improve consistency of all dietary messages re: importance of reducing the frequency of consumption of sugary drinks and foods Ensure effective dietary education for those at risk of dental caries and erosion Restriction of promotion of food and drinks high in sugar, particularly for children Encourage parents and carers to start tooth brushing with fluoride toothpaste within the first year of a child s life Incorporate oral hygiene teaching into Personal and Social Education teaching Improve the effectiveness of oral hygiene instruction provided by oral and health professional Source: Adapted from Department of Health 2005 Choosing Better Oral Health An Oral Health Plan for England London: Department of Health Available at URLhttp://wwwdhgovuk/assetRoot/04/12/32/53/ pdf Discussion with the Health Promotion team at NHS Norfolk (July 2010) identified the following examples where targeted oral health promotion either exists or could be improved: Joy of food programme Breastfeeding initiatives Healthy Start Midwives Sure Start Drug and Alcohol team Mental Health teams/camhs services Services for those with Learning Difficulty Health information leaflet service (supplies to service providers, not directly to public); in particular that the range of information could be increased if it was commissioned, as currently only free high standard (usually government) information is available All members of the primary care community teams, including health visitors and social workers Gateway (resettled refugees) Clearsprings (asylum seekers) Under one roof (services for drug misuse/homeless) Social housing Where there is care for long term neurological conditions Services dealing with obesity Health trainers; core role includes assisting a person with initial access to a dentist and an offer to accompany a person to their first appointment It was questioned whether there was secondary prevention input after a child had had a general anaesthetic for tooth extraction 53

56 Substitute prescribing, eg shared care: sugar free methadone Prison health services Older people with malnutrition (particularly in care homes): an imminent/current initiative Summary Points - Section 4 Prevention services There is natural fluoride in Norfolk water supplies, but at a lower than optimal level to prevent tooth decay, a problem which is a greater risk for vulnerable groups School dental screening services are not the most efficient way to improve dental health, but can be most beneficial in special schools or schools serving pupils of highest need The dental check up is included in the Marmot Review on health inequality as a preventive service Dental check ups are delivered in Norfolk chiefly through the dental contract as one UDA and the target is that 63% of the NHS Norfolk population accesses this service at least once in 24 months, up from the current uptake of just under 60% NHS Norfolk is working with providers to ensure that frequency of check ups for any individual is decided in line with NICE guidance Evidence based oral health promotion services are beneficial and cost effective if directed appropriately to particular population groups Collaborative work between the specialised dental oral health promotion team, consultant in dental public health and leaders of other services is recommended, including better, consistent information on self care and services that include regular professional application of fluoride varnish, by dentists or specifically trained members of a dental team 54

57 Part 2: Dental Care Pathways, services in Norfolk, gaps, efficiencies and productivity Section 5: Dental Care Pathways 51 Overview of system Professor Steele, in his independent review of NHS dental services in England (July 2009), presents a clear view of what NHS dentistry should offer : A lifetime-focused, evidence-based oral health service, which aims: To prevent oral disease and the damage it causes To minimise the impact of oral disease on your health, when it occurs To maintain and restore quality of life when this is affected by the condition of your mouth Professor Steele states that there should be clarity and consistency to what NHS dentistry can and should offer to patients and outlines these in a diagram based on a pyramid, reproduced below (Figure 24) Towards the base are things he describes as at the heart of any dental system and at the top are advanced and expensive services which should be considered if public resources stretch that far Hence resource would be invested properly in health, with a long term oral health goal The various levels can be ordered into a simple pathway so that patients and dentists can see where and how the different elements are offered Figure 24: Priorities for investment in oral health (Steele 2009) Advanced and complex care Continuing care High quality routine treatment of dental Personalised disease prevention Urgent care and pain relief Public health Reducing priority for public investment The argument for each of these layers is considered in the table that follows (Table 13), with a comment on potential impact on secondary care service costs 55

58 Priorities for public investment Public Health Urgent care Personalised disease prevention Routine treatment and continuing care Advanced, complex and expensive treatments Steele rationale Strong, co coordinated system, recognising common risks and providing support to profession and info to patients on how to minimise risks Quick, definitive pain relief to anyone who needs it; relatively inexpensive High priority for investment at individual level as failure results in cavity or periodontal pockets that are irreversible damage, with lifetime consequences and costs Quality primary care and continuing card as oral health is a lifetime concept Offered for quality of life rather than disease management; not an automatic right for everyone but targeted to where risks are managed and where need and benefits greatest Comments Strong evidence of association between prevalence of oral cancers (expensive to treat in secondary care) and smoking and alcohol use Traumatic facial injury can result from violence/accidents related to alcohol misuse Smoking exacerbates periodontal disease hence risk of tooth loss Links between sugars in diet and tooth decay Delaying seeking help for dental pain can result in severe dental infections that may need admission This happens quite rarely, but is reported to be on the increase Population groups who do not use current services regularly, with poorer dental health are more likely to need services for urgent care and ultimately secondary care for complex oral surgery that might arise A large population group will benefit; rectifying where prevention fails, and where restorations don t last is currently the majority of work in primary care The current impact on secondary care is where need arises for difficult oral surgery or more complex restorative work although the latter is not routinely provided at specialist level or in secondary care A large population group already benefits and there would be high demand for specialist care if it was available Currently there is an advice only service re complex restorative care provided in secondary care setting in Norfolk, mainly to support dentists treatment planning For secondary care this includes dental implants for eg severe facial deformity or facial reconstruction after a major accident or following cancer surgery Implant surgery is becoming more available in primary care, but it is not funded by the NHS Table 13 Priorities for investment in oral health and their impact on secondary care service costs 56

59 52 Current pathways for dental care in Norfolk: For most people, a visit to a dentist (General Dental Practitioner, GDP) is all that needs to happen to allow access to all the care and treatment required At the end of the course of treatment, the GDP will advise when the next check up should be, which may be between 3 months and two years depending on the patient s need Referrals might occur in the following circumstances: A child assessed to have orthodontic needs, to an orthodontic service, which may be secondary or primary care based, provided by a consultant, specialist or dentist with a special interest There is a PCT referral management service An adult with severe dental anxiety, that cannot be managed at the chairside, to a sedation service A child with high treatment need and behavioural management issues, to the salaried dental service where as a last resort, a hospital based general anaesthetic can be given An adult requiring extractions that are technically difficult to an oral surgery service which may be secondary or primary care based, provided by a consultant, specialist or dentist with a special interest There is a PCT referral management service A person with complex treatment needs, to a secondary care based restorative consultant for an opinion and treatment plan to assist the general dentist A person with complex management needs, for example due to severe learning disability, to the salaried dental service Section 13 below provides data on the various services and approximate resource in each sector of dentistry in Norfolk, excluding the spend on primary care based oral surgery: 53 Overall spend Area of spend General dental services (10/11 prices) including orthodontic, sedation, some domiciliary care, out of hours and prison Approx annual % amount 27, * 83 Oral surgery service in primary care Secondary care: Acute outpatients Daycases/Inpatients (09/10) Salaried community services (09/10) Community dental service Access 2,005,800 1,252,100 2,265,961 7 Total (approx) 33,380, *Also there is revenue from patient charges of 11,191m It is clear that the majority of spend is in general dental services

60 Summary points - Section 5 Professor Steele, in his independent review of dentistry in 2009, provided a priority framework for public investment in oral health Fundamental was urgent care and pain relief, followed by personalised disease prevention, high quality routine treatment of dental disease, continuing care and lastly, advanced and complex care Most (83%) dental prevention and treatment takes place through general dental services, supported by some specialised areas on referral The second largest, 10% is services provided by the salaried provider that caters for more vulnerable clients and specialised areas of care 58

61 Section 6: Current Service Provision 61 General Dental Services By Rachel Field A new dental contract was introduced in England and Wales on` 1 st April 2006, bringing a fundamental reform of the remuneration system Under the new contract, dentists are paid an agreed annual contract, on the basis of completed courses of treatment Each course of treatment is allocated a number of units of dental activity (UDA) which dentists accumulate to meet the terms of their contract Courses of treatment are classified into treatment bands according to their complexity Each band has an associated number of UDA s and a patient charge As at April 2010 the treatment bands and associated charges are: Treatment Band Band One Band Two Treatment included Covers examination, diagnosis, advice and a scale and polish if needed Covers everything within B1, plus further treatments such as fillings, extractions and RCT work Cost to Number of patient UDA s Band Three Covers everything within B1 and B2, plus crowns, dentures or bridges Urgent The new contract also altered the remuneration for orthodontic services, with the allocation of Units of Orthodontic activity (UOA s) to assessments (1 UOA) and case starts (21 UOA s) Domiciliary and sedation services are also contracted up to an agreed annual contractual level 62 Details the contracts currently in operation in NHS Norfolk area for all aspects of dental services It also looks at current access and activity levels, patient satisfaction and the types of treatment being performed 59

62 62 Local General Dental services provision current contracts Current contracts As at June 2010, NHS Norfolk had 98 contracts with 82 providers, for general dental services The total UDA s commissioned from these contracts as at June 2010 was 1,290,364 Contracts are held by a mixture of corporate bodies, partnerships and individuals The majority are GDS contracts; however there are also 4 PDS and 5 PDS plus contracts held Baseline contract value for general dental services is approx 323m Contract size varies greatly, from smallest at 220 UDA s (child only contract), to the largest of 52,975 UDA values also differ, ranging from 1747 to 3532, with an average of approx 2385 Location of general dental services The map on the next page details the location of all general dental practices The provision in the main Norfolk towns and Norwich is as follows: Norwich: 415,000 UDA s split over 31 practices Kings Lynn: 130,000 UDA s split over six practices Thetford: 45,500 UDA s provided by one practice Wymondham: 49,000 UDA s split over three practices Attleborough: 28,000 UDA s split over two practices (three providers) Dereham: 47,500 UDA s split over two practices (three providers) Diss: 33,800 UDA s split over three practices (four providers) 60

63 Figure 25: Map showing location of practices and their locations in Norfolk 61

64 Activity undertaken by current providers Data from the BSA 2009/2010 vital signs report shows the following: Access trends: Access rates for NHS dentistry are measured using a 24 month rolling period As at March 2010, the access rate for Norfolk based on a population estimate of 756,400 was 5728% This represents a small drop from access rates in 2006, which were 59% Figure 25: Access trend analysis for Norfolk source BSA vital signs Investment in additional dental activity and new providers has led to access rates increasing The table below illustrates the change in patient numbers between June 2009 and June 2010, with an increase of 11,376 patients Table 14: Demonstrating the changes in dental patient numbers from June 2009 June

65 63 Local Orthodontic service provision current contracts The new contract introduced in 2006 also altered the remuneration for orthodontic services, with the allocation of Units of Orthodontic activity (UOA s) to assessments (1 UOA) and case starts (21 UOA s) Since 2008, NHS Norfolk has operated a referral management centre for orthodontics Dentists are asked to refer directly to this centre, to allow effective monitoring of the numbers of referrals and avoid past problems encountered with long waiting lists and back logs The management of waiting lists is especially important as orthodontic provision falls under the guidelines of 18 week referral to treatment time (Department of Health target) Contracted activity Orthodontic services in a primary care setting are predominately based in Norwich The table below shows the UOA s currently contracted by location, with the map on the next page showing the location of practices Table 15: Orthodontic UOA s by location within Norfolk UOA Norwich (4 providers) 30,706 Swaffham 215 Thorpe 2,750 Acle 1,050 Long Stratton 53 Watton 518 Harleston 383 Loddon 579 Attleborough 460 Wymondham 1,980 Costessey 1,430 Kings Lynn 304 Roydon 709 Cromer 3,948 TOTAL 45,085 63% of UOA s currently commissioned are undertaken by dentists who restrict their practice entirely to orthodontics, with the remainder being undertaken by general dentistry providers who retain an interest in orthodontics It is not clear whether or not this spread of providers is appropriate or meeting the demands of patients needs There is provision for orthodontic treatment within a hospital setting, both at Queen Elizabeth NHS Trust in Kings Lynn, and at the Norfolk and Norwich University Hospital in Norwich 63

66 Figure 26: Orthodontic contracts in NHS Norfolk 64

67 Activity undertaken by current providers The statistics below are taken from the June 2010 Vital Signs report produced by the BSA It shows NHS Norfolk has a slightly higher rate of assess and reviews occurring when compared to the national average, which may be linked to patients being referred too early historically as practitioners were concerned about waiting times Alternatively non specialist providers may only be assessing and referring on patients to a specialist It could be argued that this does not represent best use of resources The extra funding put into orthodontics has removed this backlog and therefore it would be hoped that assessments are only carried out at appropriate ages Table 16: Rates of Access and Reviews source BSA Vital Signs Levels of referrals The total number of orthodontic referrals received through the RMC in 2009/10 was 2,481 The Vital signs report for 2009/2010 gave the following data for orthodontic activity: Patients seen for assessment that resulted in a case start: 2,281 Patients seen for assessment that were refused treatment: 763 Patients seen for assessment that were put on review: 3,266 Patients where treatment was completed in 09/10: 1,127 Patients where treatment was abandoned/discontinued in: 97 65

68 64 Local Sedation services provision current contracts The main sedation provider is based in the centre of Norwich The current contract is for 3,018 sedations per annum Dental practitioners refer directly to the practice As at September 2010, the practice had a significant waiting time for treatment of approximately six months There are a further three sedation providers with smaller contracts totalling 250 sedations per annum, all of which are located within the Norwich area Neighbouring PCT s refer into the main sedation provider, as there are no equivalent services in the areas of Suffolk, Great Yarmouth and Waveney and Lincolnshire Figure 27: Map showing sedation service provision in Norfolk Sedations performed in 2009/2010 totalled 3,761, with 3,003 of these being performed by the main provider 65 Local Domiciliary services provision current contracts The majority of domiciliary dental care is currently provided by one contractor This is contracted via an enhanced UDA value, with an activity level of 3,795 UDA s Four other providers are contracted for a very small amount of domiciliary activity, equating to 63 UDA s Contractually the main domiciliary provider must cover domiciliary visits within a ten mile radius of Norwich However, over the last two years extra activity has been awarded to the provider and therefore they have extended this to a 40 mile radius and hence cover most of NHS Norfolk This activity was temporary and has not been agreed as a permanent contract variation There are currently no domiciliary providers covering the areas further than 40 miles from Norwich During 2009/2010 there were 1,012 patients treated via domiciliary care 66

69 66 Local Access services provision current contracts The changes to the contract in 2006 meant that patients are no longer registered with a dental practice and responsibilities for urgent treatment were therefore only maintained by the dentist when the patient was in an open course of treatment Therefore, NHSN also contracts a number of urgent access facilities across the county These are centred on two access centres (Kings Lynn and Norwich), with other practices providing access sessions/slots Kings Lynn Dental Access Centre: Based on Kings Street in Kings Lynn, this centre is open from 8am till 7pm, Monday to Friday Patients can self refer to this centre or be signposted by another dental practice, health professional or PALS Siskin Dental Centre: Based at Norwich Community hospital in Bowthorpe, this centre is open from 9am till 530 pm, Monday to Friday Again patients can self refer or be signposted to the centre Practice based access slots: There are five practices with access slots which are accessed through the PALs Service Numbers of patients being seen at access slots: Data from NCH&C recently received: (there has been no validation of this data) Siskin Centre: DAC, Kings Lynn: Average of 577 patients per month Average of 815 patients per month 67 Local special care services provision current contracts Special care dentistry services are provided by NCH&C The service is aimed at those patients who by nature of their complex needs have been unable to access general dental services Examples of groups of patients accessing this service are: Adults and children with complex or special needs, including learning difficulties, where treatment with a general dentist has not been possible; Children with behaviour or management problems which make them unsuitable for treatment within general dental services; In-patients of Norfolk and Waveney Mental Healthcare Trust, where treatment with a general dentist has not been possible; Those who are housebound and require domiciliary care not available from general dental services; Adults and children who are medically compromised and require the provision of primary care dentistry in a hospital setting; Adults with Learning Difficulties and children who have been assessed by the service as requiring treatment under general anaesthesia and Orthodontic services for patients who are unsuitable for treatment in a specialist orthodontic or hospital setting Services are predominately provided from the Siskin Centre at Norwich Community Hospital, with a number of satellite clinics and use of acute care facilities for general anaesthetic cases The map below shows the location of the premises used 67

70 Figure 28: Map showing locations of special service provision in Norfolk Numbers of patients being seen/sessions being provided Data from NCH&C recently received: (there has been no validation of this data) Location Full staff complement Average Session/wk Current Average Sessions/wk Current Activity Patients appts Average/month Siskin 54 Special Care 28 Access Special Care 175 Access Thorpe Bowthorpe Norvic N Walsham Dereham Attleborough Sheringham Hoveton Swaffham Downham Mkt St James, KL Terrington Hunstanton King s St KL Access only 33 Access only over 7days over 7 days HMP Wayland HMP Norwich HMP Bure Total ,688 68

71 Summary points Section 6 Current service provision, general dental services Patients understand three bands of treatment for primary care dentistry, which attract a charge unless the patient is exempted, which includes all children The dentist delivers the contract to the PCT usually in a currency of UDAs There are 98 contracts with 82 providers, delivering 1,290,364 UDAs with a baseline contract value of 323M, the average UDA rate being 2385 Services have been mapped, to assess access across the county and distribution of spread, particularly in relation to market towns and roads Access rates to NHS primary care dental services in Norfolk over 24 months are 5728% and the positive impact on this figure, due to new providers from recent commissioning and investment is still being realised Orthodontics Measure of orthodontic activity is the UOA; a case start attracts 21, and assessment, 1 Referrals into the service are now centralised through a referral management service which enables monitoring, evaluation and equitable services for patients For historical reasons, most services are in Norwich, and there are many small contracts scattered between providers of general dental services Some orthodontic services are provided in hospitals, via out patients, this is particularly important for access in West Norfolk Norfolk patients were receiving higher rates of assessment and review, relative to other areas of the country There was a backlog of cases waiting to start treatment and in 2009/10, 2,481 patient referrals were received to the referral management service It is not clear whether current spread of orthodontic provision meets patient s needs and is good vfm Sedation The main provider of sedation services is a single practice in Norwich that provides 3,018 sedations, on direct referral Waiting times are long, with many patients referred from neighbouring PCT areas Domiciliary services: Mainly a single provider in general dental services 3,858 UDAs per year, with 1,012 patients treated in 2009/10 Local access provision Urgent access (during normal clinical hours) is provided at Kings Lynn and Norwich, which between them see about 1,390 patients per month In addition, other practices provide some slots or sessions Some of the sessions can be accessed only on enquiry to the NHS Norfolk PALS service Special care services Special care dentistry is more appropriate for some individuals, usually from vulnerable groups Most services are in Norwich and Kings Lynn but there are a number of part time clinics around the county 69

72 Section 7: Secondary care & referral Management 71 Hospital out patients (all secondary care data in this section needs to be verified) For the year 2009/10, the total spend on outpatients for the oral and dental specialties including orthodontics was 2,265,961, on a total activity of 25,916 contacts This covers all Norfolk residents over a very wide range of hospitals across the country Many of the visits distant from Norfolk were isolated ones, suggesting that the person was on a visit to a different part of the country when experiencing a problem The following table is a selection of 13 different hospitals where the numbers of attendances were greater Table 17: Comparative Secondary Care Referrals Hospital Oral Surgery contacts Orthodontic contacts 1 Barts and London Bedford 5 3 Cambridge OMFS 287/OS East Kent Guys Ipswich James Paget Kings Norfolk & Norwich University Hospital 12,390 4, Peterborough QE 4,213 1, UCL 28 OMFS/15 OS West Suffolk (OMFS = Oral and Maxillofacial surgery; OS= Oral Surgery) A single orthodontic outpatient appointment can attract a charge of around 182 The contacts included on the table above cost 223M 70

73 72 Daycases (emergency and elective) Between Norfolk and Norwich University Hospital (NNUH) and the Queen Elizabeth (QE) there were 4,136 procedures undertaken, at a cost of 2,906,735, the overwhelming majority being oral surgery, most of which are elective day cases Each of the hospitals is considered separately below: Queen Elizabeth Hospital: There were 1465 procedures, priced at , 2009/10 prices Picking out cases that were limited to dental rather than soft tissue or more complex surgery, the following table shows that 1165 (80%) of these procedures ( ) fell within these categories: Table 18: Secondary care QEH activity data selected procedures 2009/10 Procedure Number done Cost 1 Surgical exposure of tooth 8 4,824 2 Surgically impacted tooth 30 18,459 3 Surgically impacted wisdom tooth ,992 4 Surgical removal of retained tooth ,297 5 Surgical removal of tooth ,254 6 Surgical removal of wisdom tooth ,723 7 Single tooth extraction ,865 8 Surgical removal of tooth 5 3,236 9 Upper clearance 4 2, Extraction of multiple teeth , Full clearance 20 13, Lower dental clearance Total 1, ,532 Norfolk and Norwich University Hospital Total NNUH activity was 2,671 procedures, priced at 2,056,293 The data on selected procedures below cover 39% of all procedures and 34% costs Table 19: Secondary care NNUH Activity data 2009/10 Procedure Number done Cost 1 Apicectomy 17 10,900 2 Extraction, multiple teeth ,914 3 Clearance 38 29,593 4 Lower clearance 5 3,192 5 Other tooth 5 2,455 6 Surgical exposure of tooth 49 35,267 7 Surgical removal of impacted tooth 80 56,928 8 Surgical removal of impacted ,963 wisdom tooth 9 Surgical removal; retained root 88 56, Surgical removal tooth , Surgical removal wisdom tooth , Upper Clearance 11 8,119 Total 1, ,174 71

74 73 Referral management Orthodontics In the year 2009/10, the total number of orthodontic referrals received through the RMS for 2009/10 was 2481 Of the 2481 received 1106 had an assessment 451 went on to have a brace fitted It is expected to find a ratio of assessments to case starts of about 2:1 In Norfolk in the previous year, NHSN was working to clear a backlog of waiting cases Further work is underway to clarify capacity and patient flows, and to improve quality monitoring of referrals The following graph shows referrals by age of patient in 2009/10 Figure 28: Orthodontic referrals by age 2009/10 Orthodontic referrals by Age 2009/ No of referrals received Age of Patients Oral surgery referrals NHS Norfolk has contracts with a number of specialist providers of minor oral surgery services to ease the load on the acute trust and referral pathways have been consolidated with the Trust Between April and July 2010, 1,301 referrals were received and triaged by the dental adviser 451 were passed to the hospital and the remainder shared between the specialist providers Projected expenditure on the primary care element for the current year, based on current referral rate and division between hospital and specialist is 514,000 Referrals are increasingly closely scrutinised and NHSN is working with dentists who refer more frequently 72

75 Section 8: Public Voice 81 National Surveys By Wendy Napier Dentistry Watch In 2007, the Commission for Patient and public involvement in Health conducted a national survey to find out what patients really think about NHS dental services Members from local Patient and Public Information Forums asked a total of 5,212 patients for their views on crucial issues regarding dental services across the country between July and September 2007 The resulting Dentistry Watch report was published in October 2007 liv The main findings of this survey were as follows: liv 93% of NHS patients are happy with the treatment they receive Almost a fifth of patients have gone without treatment because of the cost Almost half of all NHS patients do not understand NHS dental charges 78% of patients using private dental services are doing so because either their dentist stopped treating NHS patients (49%), or because they could not find an NHS dentist (29%) 35% of those not currently using dental services stated it is because there is not an NHS dentist near where they live Citizen s Advice Bureau Survey The Department of Health recommends that people searching for an NHS dentist should contact either their PCT or NHS Direct A recent report from the Citizen s Advice Bureau, however, suggests that these search strategies are not well used (see Figure 29) lv In the East of England, for example, around 63% of patients heard about their current dentist from friends and family and around 42% do not know how to get emergency treatment outside office hours (Dentistry Watch Report, 2007) This means that even where services are available, people may not be able to access them 73

76 Figure 29: Citizen s Advice Bureau Data on How People Go About Finding an NHS Dentist Source: CAB Evidence Briefing Gaps to fill CAB evidence on the first year of the NHS dentistry reforms March 2007 Available at URL: The CAB found that 65% of people who were unable to find an NHS dentist simply went without treatment (see Figure 30) Figure 30: The Course of Action Taken by Respondents if Citizens Advice Bureau Survey Who Were Unable to Find an NHS Dentist Source: CAB Evidence Briefing Gaps to fill CAB evidence on the first year of the NHS dentistry reforms March 2007 Available at URL: 74